The effects of an aerobic and resistance exercise training program on cognition following stroke

Dissecting the causal relationship between moderate to vigorous physical activity levels and cognitive performance: a bidirectional two-sample Mendelian randomization study

Introduction

Recent studies increasingly suggest that moderate-to-vigorous physical activity (MVPA) impacts cognitive risk. However, the bidirectional nature of this relationship warrants further exploration. To address this, we employed a Mendelian randomization (MR) approach, analyzing two distinct samples.

Methods

These analyses utilized published genome-wide association study (GWAS) summary statistics for MVPA (n = 377,234) and cognitive performance (n = 257,841). Our primary method was the inverse variance weighted (IVW) model with random effects, aiming to deduce potential causal links. Additionally, we employed supplementary methods, including MR Egger regression, Weighted median, Weighted mode, and Simple mode. For sensitivity analysis, tools like the MR Egger test, Cochran's Q, MR PRESSO, and leave-one-out (LOO) were utilized.

Results

Our findings indicate a decrease in cognitive risk with increased MVPA (Odds Ratio [OR] = 0.577, 95% Confidence Interval [CI]: 0.460-0.723, p = 1.930 × 10-6). Furthermore, enhanced cognitive levels corresponded to a reduced risk of inadequate MVPA (OR = 0.866, 95% CI: 0.839-0.895, p = 1.200 × 10-18).

Discussion

In summary, our study demonstrates that MVPA lowers cognitive risk, while poor cognitive health may impede participation in MVPA. Overall, these findings provide valuable insights for developing personalized prevention and intervention strategies in health and sports sciences.

Effect of matcha green tea on cognitive functions and sleep quality in older adults with cognitive decline: A randomized controlled study over 12 months

OBJECTIVE

Lifestyle habits after middle age significantly impact the maintenance of cognitive function in older adults. Nutritional intake is closely related to lifestyle habits; therefore, nutrition is a pivotal factor in the prevention of dementia in the preclinical stages. Matcha green tea powder (matcha), which contains epigallocatechin gallate, theanine, and caffeine, has beneficial effects on cognitive function and mood. We conducted a randomized, double-blind, placebo-controlled clinical study over 12 months to examine the effect of matcha on cognitive function and sleep quality.

METHODS

Ninety-nine participants, including 64 with subjective cognitive decline and 35 with mild cognitive impairment were randomized, with 49 receiving 2 g of matcha and 50 receiving a placebo daily. Participants were stratified based on two factors: age at baseline and APOE genotype. Changes in cognitive function and sleep quality were analyzed using a mixed-effects model.

RESULTS

Matcha consumption led to significant improvements in social acuity score (difference; -1.39, 95% confidence interval; -2.78, 0.002) (P = 0.028) as evaluated by the perception of facial emotions in cognitive function. The primary outcomes, that is, Montreal Cognitive Assessment and Alzheimer's Disease Cooperative Study Activity of Daily Living scores, showed no significant changes with matcha intervention. Meanwhile, Pittsburgh Sleep Quality Index scores indicated a trend toward improvement with a difference of 0.86 (95% confidence interval; -0.002, 1.71) (P = 0.088) between the groups in changes from baseline to 12 months.

CONCLUSIONS

The present study suggests regular consumption of matcha could improve emotional perception and sleep quality in older adults with mild cognitive decline. Given the widespread availability and cultural acceptance of matcha green tea, incorporating it into the daily routine may offer a simple yet effective strategy for cognitive enhancement and dementia prevention.

A Comparison of Test-Retest Reliability and Practice Effects of Short Portable Mental State Questionnaire and Montreal Cognitive Assessment in Patients with Stroke

OBJECTIVE

To compare the test-retest reliabilities and minimal detectable change (MDC) of the Short Portable Mental State Questionnaire (SPMSQ) and the Montreal Cognitive Assessment (MoCA) in patients with stroke.

METHODS

63 patients were recruited from 1 medical center. The SPMSQ and MoCA were administered twice, 2 weeks apart.

RESULTS

Both measures showed high intraclass correlation coefficients (SPMSQ: 0.87; MoCA: 0.89) and acceptable MDC%s (SPMSQ: 14.8%; MoCA: 19.6%). A small correlation (r = 0.30) was found between the absolute difference and average in each pair of assessments in the SPMSQ, which was close to the criterion of heteroscedasticity. A small practice effect was observed in the MoCA (Cohen's d = 0.30).

CONCLUSION

The SPMSQ demonstrated smaller random measurement error and an absence of practice effect. When comparing the psychometric properties of the SPMSQ and MoCA as outcome measures for assessing cognitive function in patients with stroke, the SPMSQ appears to be a more suitable choice than the MoCA.

Sex Differences in Depressive Symptoms in 1308 Patients Post-Stroke at Entry to Cardiac Rehabilitation

PURPOSE

The objective of this study was to determine whether a sex difference exists in the prevalence of post-stroke depressive symptoms (PSDS) at entry to cardiac rehabilitation (CR) and to determine the correlates of PSDS in all patients, and in women and men separately.

METHODS

People post-stroke at entry to CR from database records (2006-2017) were included. Bivariate analyses identified PSDS correlates (≥16 on the Center for Epidemiologic Studies Depression Scale) in all patients and women and men separately.

RESULTS

Patients (n = 1308, 28.9% women), mean age of 63.9 ± 12.9 yr, were 24.2 ± 9.9 mo post-stroke at CR entry. Among all patients, 30.0% had PSDS. A greater proportion of women than men had PSDS (38.6 vs 26.6%; P < .001). Correlates of PSDS in all patients were sex (women) (OR = 1.6: 95% CI, 1.14-2.12), being unemployed, ≤60 yr old, prescribed antidepressant medication, having lower cardiorespiratory fitness (peak oxygen uptake [V̇ o2peak ]), chronic obstructive pulmonary disease (COPD), higher body mass index (BMI), no transient ischemic attack, and longer time from stroke to CR entry (>12 mo). Correlates in women were being obese (BMI ≥ 30), 51-70 yr old, prescribed antidepressant medication, and not married. Correlates in men were being ≤60 yr old, unemployed, prescribed antidepressant medication, having lower V̇ o2peak , sleep apnea, COPD, and no hypertension.

CONCLUSION

Women were disproportionately affected by PSDS at entry to CR in bivariate and multivariable analyses. Women and men had mostly unique correlates of PSDS, indicating tailored strategies to address PSDS are required. PSDS disproportionately affected patients with longer delay to CR entry, suggesting efforts should target timely referral to facilitate earlier and repeated assessments and management.

Patients' Perceptions of Hybrid and Virtual-Only Care Models During the Cardiac Rehabilitation Patient Journey: A Qualitative Study

BACKGROUND

The COVID-19 pandemic initially led to discontinuation of the "traditional" center-based cardiac rehabilitation (CR) model. Virtual models emerged as an opportunity to deliver care, with many programs continuing to offer these models.

OBJECTIVE

The aim of this study was to explore patients' perceptions of virtual models of either hybrid (combining center-based and virtual) or virtual-only CR since the pandemic.

METHODS

Men and women who chose to participate in hybrid or virtual CR models between January 2022 and January 2023 were invited to attend 1 of 8 focus group sessions. Focus groups were conducted online until thematic saturation was reached. Transcripts were analyzed using thematic analysis.

RESULTS

Twenty-three patients (48% female; 83% attending hybrid CR) participated in the study. Analysis revealed 12 overarching themes associated with the CR patient journey: pre-CR, namely, (1) importance of endorsement from healthcare providers and (2) need for education/communication while waiting for program initiation; during CR, namely, (3) preference for class composition/structure, (4) need to enhance peer support in the virtual environment, (5) convenience and concerns with virtual sessions, (6) necessity of on-site sessions, (7) safety of the exercise prescription, (8) requirement/obligation for allied health offerings, (9) satisfaction with virtual education, and (10) use of technology to facilitate CR participation; and post-CR, namely, (11) acknowledgment of program completion and (12) need for support/education after program graduation.

CONCLUSIONS

Patients require ongoing support from time of referral to beyond CR program completion. Physical, psychosocial, nutritional, and educational supports are needed. Perceptions expressed by patients related to the program model are modifiable, and strategies to address these perceptions should be explored.

Effect of High-Intensity Interval Training and Moderate-Intensity Continuous Training in People With Poststroke Gait Dysfunction: A Randomized Clinical Trial

BACKGROUND

The exercise strategy that yields the greatest improvement in both cardiorespiratory fitness (V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ ) and walking capacity poststroke has not been determined. This study aimed to determine whether conventional moderate-intensity continuous training (MICT) or high-intensity interval training (HIIT) have different effects on V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ and 6-minute walk distance (6MWD).

METHODS AND RESULTS

In this 24-week superiority trial, people with poststroke gait dysfunction were randomized to MICT (5 days/week) or HIIT (3 days/week with 2 days/week of MICT). MICT trained to target intensity at the ventilatory anaerobic threshold. HIIT trained at the maximal tolerable treadmill speed/grade using a novel program of 2 work-to-recovery protocols: 30:60 and 120:180 seconds. V̇O2 and heart rate was measured during performance of the exercise that was prescribed at 8 and 24 weeks for treatment fidelity. Main outcomes were change in V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ and 6MWD. Assessors were blinded to the treatment group for V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ but not 6MWD. Secondary outcomes were change in ventilatory anaerobic threshold, cognition, gait-economy, 10-meter gait-velocity, balance, stair-climb performance, strength, and quality-of-life. Among 47 participants randomized to either MICT (n=23) or HIIT (n=24) (mean age, 62±11 years; 81% men), 96% completed training. In intention-to-treat analysis, change in V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ for MICT versus HIIT was 2.4±2.7 versus 5.7±3.1 mL·kg-1·min-1 (mean difference, 3.2 [95% CI, 1.5-4.8]; P<0.001), and change in 6MWD was 70.9±44.3 versus 83.4±53.6 m (mean difference, 12.5 [95% CI, -17 to 42]; P=0.401). HIIT had greater improvement in ventilatory anaerobic threshold (mean difference, 2.07 mL·kg-1·min-1 [95% CI, 0.59-3.6]; P=0.008). No other between-group differences were observed. During V̇O2 monitoring at 8 and 24 weeks, MICT reached 84±14% to 87±18% of V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ while HIIT reached 101±22% to 112±14% of V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ (during peak bouts).

CONCLUSIONS

HIIT resulted in more than a 2-fold greater and clinically important change in V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ than MICT. Training to target (ventilatory anaerobic threshold) during MICT resulted in ~3 times the minimal clinically important difference in 6MWD, which was similar to HIIT. These findings show proof of concept that HIIT yields greater improvements in cardiorespiratory fitness than conventional MICT in appropriately screened individuals.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03006731.

A Randomized Controlled Trial to Evaluate the Impact of an Exercise Therapy Program Based on Sports in People with Acquired Brain Injury: Discover Study Protocol

INTRODUCTION

Acquired brain injury (ABI) constitutes a significant and growing global public health concern. People with ABI often face a range of physical and psychosocial challenges that span the domains of "body structure and function", "activity", and "participation", as defined by the International Classification of Functioning, Disability, and Health. Multidisciplinary approaches based on exercise therapy with social leisure activities are essential to improve physical recovery and health-related quality of life after injury.

METHODS

Adults with ABI, aged > 18 years, in the subacute or chronic stage (within more than one month after the injury) will be recruited through a rehabilitation center. Adults will be randomized to receive either a racket sports-based exercise therapy program combined with usual care (sET) or usual care alone (UC) using a random number sequence with a 1:1 allocation ratio. sET intervention consists of an 8-week exercise therapy program focusing on different racket sports skills, 1 h in duration, 2 days/week. It will be delivered by a physiotherapist in tailored, face-to-face, group-based sessions. Primary outcomes will be the health-related quality of life (SF-36) and upper extremity motor function (Fugl-Meyer Assessment-Upper Extremity Scale).

DISCUSSION

The study proposes an intervention that combines sports-based exercise therapy with usual care. It aims to determine whether this intervention improves the health-related quality of life and upper limb motor function in adults with ABI compared with usual care alone. The results of this study may have clinical implications for the rehabilitation of this population.

Examination of the Accuracy of Movement Tracking Systems for Monitoring Exercise for Musculoskeletal Rehabilitation

When patients perform musculoskeletal rehabilitation exercises, it is of great importance to observe the correctness of their performance. The aim of this study is to increase the accuracy of recognizing human movements during exercise. The process of monitoring and evaluating musculoskeletal rehabilitation exercises was modeled using various tracking systems, and the necessary algorithms for processing information for each of the tracking systems were formalized. An approach to classifying exercises using machine learning methods is presented. Experimental studies were conducted to identify the most accurate tracking systems (virtual reality trackers, motion capture, and computer vision). A comparison of machine learning models is carried out to solve the problem of classifying musculoskeletal rehabilitation exercises, and 96% accuracy is obtained when using multilayer dense neural networks. With the use of computer vision technologies and the processing of a full set of body points, the accuracy of classification achieved is 100%. The hypotheses on the ranking of tracking systems based on the accuracy of positioning of human target points, the presence of restrictions on application in the field of musculoskeletal rehabilitation, and the potential to classify exercises are fully confirmed.

Sex differences and predictors of completion of a 6-month exercise-based cardiac rehabilitation program in 1,536 people following stroke

OBJECTIVE

To retrospectively examine sex-differences and predictors of completion in consecutively-referred patients to a 6-month exercise-based cardiac rehabilitation program (CRP) from 2006 to 2017.

MATERIALS/METHODS

People with hemiplegic gait participated in stroke-adapted-CRP; otherwise, traditional-CRP. Reasons for non-completion were ascertained by interview. Regression-analyses were conducted to determine non-completion in all patients and women and men separately.

RESULTS

There were 1536 patients (30.3% women), mean age 64.5 ± 12.5 with 23% initiating the stroke-adapted-CRP. Overall, 75.1% completed the CRP (87.3% stroke-adapted-CRP vs 71.5% traditional-CRP; p < .001). There was no difference in completion between women and men (74.5% vs 75.4%; p=0.7), or in attendance to pre-scheduled sessions (p=0.6) or reasons for non-completion (p > .05, all). The only sex difference in completion by age (decade) occurred in those <41 years (59% women vs 85% men; p=.02). Baseline predictors of non-completion among all patients included not being enrolled in the stroke-adapted-CRP, lower V̇O_2peak, smoking, diabetes (prescribed insulin) and depression but not sex (p=.5) or age (p=.15). Unique predictors in women vs men were younger age, lower V̇O_2peak, smoking, diabetes (prescribed insulin), depression, and cancer diagnoses. Unique to men was having >1 stroke and diabetes (any anti-diabetes medication). The strongest predictor of non-completion among all models was not being enrolled in stroke-adapted-CRP.

CONCLUSIONS

While there were no sex-differences in adherence to the CRP, women and men have mostly unique predictors of non-completion. Younger women are at greatest risk for non-completion. Practitioners should provide sex-specific, tailored strategies for enhancing completion with a focus on younger women and offering a stroke-adapted-CRP with close attention to those with diabetes.

Optimal Intensity and Duration of Walking Rehabilitation in Patients With Chronic Stroke: A Randomized Clinical Trial

Importance

For walking rehabilitation after stroke, training intensity and duration are critical dosing parameters that lack optimization.

Objective

To assess the optimal training intensity (vigorous vs moderate) and minimum training duration (4, 8, or 12 weeks) needed to maximize immediate improvement in walking capacity in patients with chronic stroke.

Design, Setting, and Participants

This multicenter randomized clinical trial using an intent-to-treat analysis was conducted from January 2019 to April 2022 at rehabilitation and exercise research laboratories. Survivors of a single stroke who were aged 40 to 80 years and had persistent walking limitations 6 months or more after the stroke were enrolled.

Interventions

Participants were randomized 1:1 to high-intensity interval training (HIIT) or moderate-intensity aerobic training (MAT), each involving 45 minutes of walking practice 3 times per week for 12 weeks. The HIIT protocol used repeated 30-second bursts of walking at maximum safe speed, alternated with 30- to 60-second rest periods, targeting a mean aerobic intensity above 60% of the heart rate reserve (HRR). The MAT protocol used continuous walking with speed adjusted to maintain an initial target of 40% of the HRR, progressing up to 60% of the HRR as tolerated.

Main Outcomes and Measures

The main outcome was 6-minute walk test distance. Outcomes were assessed by blinded raters after 4, 8, and 12 weeks of training.

Results

Of 55 participants (mean [SD] age, 63 [10] years; 36 male [65.5%]), 27 were randomized to HIIT and 28 to MAT. The mean (SD) time since stroke was 2.5 (1.3) years, and mean (SD) 6-minute walk test distance at baseline was 239 (132) m. Participants attended 1675 of 1980 planned treatment visits (84.6%) and 197 of 220 planned testing visits (89.5%). No serious adverse events related to study procedures occurred. Groups had similar 6-minute walk test distance changes after 4 weeks (HIIT, 27 m [95% CI, 6-48 m]; MAT, 12 m [95% CI, -9 to 33 m]; mean difference, 15 m [95% CI, -13 to 42 m]; P = .28), but HIIT elicited greater gains after 8 weeks (58 m [95% CI, 39-76 m] vs 29 m [95% CI, 9-48 m]; mean difference, 29 m [95% CI, 5-54 m]; P = .02) and 12 weeks (71 m [95% CI, 49-94 m] vs 27 m [95% CI, 3-50 m]; mean difference, 44 m [95% CI, 14-74 m]; P = .005) of training; HIIT also showed greater improvements than MAT on some secondary measures of gait speed and fatigue.

Conclusions and Relevance

These findings show proof of concept that vigorous training intensity is a critical dosing parameter for walking rehabilitation. In patients with chronic stroke, vigorous walking exercise produced significant and meaningful gains in walking capacity with only 4 weeks of training, but at least 12 weeks were needed to maximize immediate gains.

Trial Registration

ClinicalTrials.gov Identifier: NCT03760016.

Combined Aerobic Exercise and Virtual Reality-Based Upper Extremity Rehabilitation Intervention for Chronic Stroke: Feasibility and Preliminary Effects on Physical Function and Quality of Life

Objectives

To (1) examine the feasibility of combining lower extremity aerobic exercise (AEx) with a virtual reality (VR) upper extremity (UE) rehabilitation intervention and (2) provide an estimate of effect size for the combined intervention on UE function, aerobic capacity, and health-related quality of life.

Design

Single-group feasibility trial.

Setting

Research laboratory.

Participants

Community-dwelling individuals with mild to moderate impairment of the UE at least 6 months post stroke (N=10; male, n=6; female n=4; mean age, 54 years).

Intervention

All participants received 18 sessions over a nominal 2-3 sessions per week schedule of a combined AEx and VR-UE rehabilitation intervention. During each session, participants completed 15 minutes of lower extremity AEx followed by playing a VR-UE rehabilitation game for approximately 20 minutes.

Main Outcome Measures

Feasibility was evaluated by metrics of adherence, retention, treatment acceptability, data completeness, and adverse events. UE function, aerobic capacity (peak oxygen consumption [Vo2peak]), and quality of life were assessed with the Fugl-Meyer Assessment of Upper Extremity (FMA-UE), expired gas exchange analysis, and Stroke Impact Scale (SIS), respectively.

Results

Adherence was 100%, and there were no withdrawals or losses to follow-up to report. Participants completed the intervention in 49±14 days. Cohen's dz effect size calculations indicated the intervention elicited medium effects on FMA-UE (dz =0.50) and SIS memory domain (dz =0.46) and large effects on absolute Vo2peak (dz =1.46), relative Vo2peak (dz =1.21), SIS strength (dz =1.18), and SIS overall recovery domains (dz =0.81).

Conclusions

Combining lower extremity AEx and VR-UE rehabilitation appears feasible in the clinical research setting. Fifteen minutes of lower extremity AEx performed at vigorous intensity appears to elicit clinically meaningful benefits in chronic stroke. Further examination of the combination of lower extremity AEx and VR-UE rehabilitation and its effects on physical function and quality of life is warranted.

Training parameters and longitudinal adaptations that most strongly mediate walking capacity gains from high-intensity interval training post-stroke

Background

Locomotor high-intensity interval training (HIIT) has been shown to improve walking capacity more than moderate-intensity aerobic training (MAT) after stroke, but it is unclear which training parameter(s) should be prioritized (e.g. speed, heart rate, blood lactate, step count) and to what extent walking capacity gains are the result of neuromotor versus cardiorespiratory adaptations.

Objective

Assess which training parameters and longitudinal adaptations most strongly mediate 6-minute walk distance (6MWD) gains from post-stroke HIIT.

Methods

The HIT-Stroke Trial randomized 55 persons with chronic stroke and persistent walking limitations to HIIT or MAT and collected detailed training data. Blinded outcomes included 6MWD, plus measures of neuromotor gait function (e.g. fastest 10-meter gait speed) and aerobic capacity (e.g. ventilatory threshold). This ancillary analysis used structural equation models to compare mediating effects of different training parameters and longitudinal adaptations on 6MWD.

Results

Net gains in 6MWD from HIIT versus MAT were primarily mediated by faster training speeds and longitudinal adaptations in neuromotor gait function. Training step count was also positively associated with 6MWD gains, but was lower with HIIT versus MAT, which decreased the net 6MWD gain. HIIT generated higher training heart rate and lactate than MAT, but aerobic capacity gains were similar between groups, and 6MWD changes were not associated with training heart rate, training lactate, or aerobic adaptations.

Conclusions

To increase walking capacity with post-stroke HIIT, training speed and step count appear to be the most important parameters to prioritize.

Impact of cognitive capacity on physical performance in chronic obstructive pulmonary disease patients: A scoping review

Background: Chronic obstructive pulmonary disease (COPD) is often accompanied by impaired cognitive and physical function. However, the role of cognitive function on motor control and purposeful movement is not well studied. The aim of the review was to determine the impact of cognition on physical performance in COPD. Methods: Scoping review methods were performed including searches of the databases: MEDLINE, EMBASE, Cochrane Systematic Reviews, Cochrane (CENTRAL), APA PsycINFO, and CINAHL. Two reviewers independently assessed articles for inclusion, data abstraction, and quality assessment. Results: Of 11,252 identified articles, 44 met the inclusion criteria. The review included 5743 individuals with COPD (68% male) with the forced expiratory volume in one second range of 24-69% predicted. Cognitive scores correlated with strength, balance, and hand dexterity, while 6-min walk distance (n = 9) was usually similar among COPD patients with and without cognitive impairment. In 2 reports, regression analyses showed that delayed recall and the trail making test were associated with balance and handgrip strength, respectively. Dual task studies (n = 5) reported impaired balance or gait in COPD patients compared to healthy adults. Cognitive or physical Interventions (n = 20) showed variable improvements in cognition and exercise capacity. Conclusions: Cognition in COPD appears to be more related to balance, hand, and dual task function, than exercise capacity.

The influential factors and non-pharmacological interventions of cognitive impairment in children with ischemic stroke

Background

The prevalence of pediatric ischemic stroke rose by 35% between 1990 and 2013. Affected patients can experience the gradual onset of cognitive impairment in the form of impaired language, memory, intelligence, attention, and processing speed, which affect 20-50% of these patients. Only few evidence-based treatments are available due to significant heterogeneity in age, pathological characteristics, and the combined epilepsy status of the affected children.

Methods

We searched the literature published by Web of Science, Scopus, and PubMed, which researched non-pharmacological rehabilitation interventions for cognitive impairment following pediatric ischemic stroke. The search period is from the establishment of the database to January 2022.

Results

The incidence of such impairment is influenced by patient age, pathological characteristics, combined epilepsy status, and environmental factors. Non-pharmacological treatments for cognitive impairment that have been explored to date mainly include exercise training, psychological intervention, neuromodulation strategies, computer-assisted cognitive training, brain-computer interfaces (BCI), virtual reality, music therapy, and acupuncture. In childhood stroke, the only interventions that can be retrieved are psychological intervention and neuromodulation strategies.

Conclusion

However, evidence regarding the efficacy of these interventions is relatively weak. In future studies, the active application of a variety of interventions to improve pediatric cognitive function will be necessary, and neuroimaging and electrophysiological measurement techniques will be of great value in this context. Larger multi-center prospective longitudinal studies are also required to offer more accurate evidence-based guidance for the treatment of patients with pediatric stroke.

Molecular mechanisms of exercise contributing to tissue regeneration

Physical activity has been known as an essential element to promote human health for centuries. Thus, exercise intervention is encouraged to battle against sedentary lifestyle. Recent rapid advances in molecular biotechnology have demonstrated that both endurance and resistance exercise training, two traditional types of exercise, trigger a series of physiological responses, unraveling the mechanisms of exercise regulating on the human body. Therefore, exercise has been expected as a candidate approach of alleviating a wide range of diseases, such as metabolic diseases, neurodegenerative disorders, tumors, and cardiovascular diseases. In particular, the capacity of exercise to promote tissue regeneration has attracted the attention of many researchers in recent decades. Since most adult human organs have a weak regenerative capacity, it is currently a key challenge in regenerative medicine to improve the efficiency of tissue regeneration. As research progresses, exercise-induced tissue regeneration seems to provide a novel approach for fighting against injury or senescence, establishing strong theoretical basis for more and more "exercise mimetics." These drugs are acting as the pharmaceutical alternatives of those individuals who cannot experience the benefits of exercise. Here, we comprehensively provide a description of the benefits of exercise on tissue regeneration in diverse organs, mainly focusing on musculoskeletal system, cardiovascular system, and nervous system. We also discuss the underlying molecular mechanisms associated with the regenerative effects of exercise and emerging therapeutic exercise mimetics for regeneration, as well as the associated opportunities and challenges. We aim to describe an integrated perspective on the current advances of distinct physiological mechanisms associated with exercise-induced tissue regeneration on various organs and facilitate the development of drugs that mimics the benefits of exercise.

Aerobic exercises and cognitive function in post-stroke patients: A systematic review with meta-analysis

OBJECTIVE

To study the effect of aerobic exercise on cognitive function of post-stroke patients, especially to identify specific interventions that the most likely to maximize cognitive benefits of stroke patients.

METHODS

According to the PRISMA principle, the databases of Web of Science, EMBASE, PubMed and Cochrane library were searched to collect randomized controlled trial data of aerobic exercise on cognitive function intervention of post-stroke patients. The Cochrane bias risk evaluation instrument was used to assess the methodological quality of included studies. Review Manager 5.4.1 software was used to analyze heterogeneity and potential publication bias.

RESULTS

A total of 11 criteria studies that satisfied the association between aerobic exercise and cognitive function following stroke were selected to be included in the review. Global cognition ability was significantly improved after aerobic exercise intervention (0.51; 95% confidence interval [CI] 0.16-0.86; P = .004), moderate intensity had the largest effect size on improving global cognition ability (0.98; 95% CI 0.48-1.47; P = .0001), none of cognitive flexibility, working memory, selective attention and conflict resolution showed the significant difference from zero.

CONCLUSION

Aerobic exercise has a good impact on enhancing the cognitive dysfunction of patients after stroke, which stroke patients were found to benefit the most from moderate-intensity exercise. However, our studies did not found that aerobic exercise had an active result on cognitive flexibility, working memory, selective attention and contention resolution.

Effect of an exercise intervention on global cognition after transient ischemic attack or minor stroke: the MoveIT randomized controlled trial

BACKGROUND

Patients with a transient ischemic attack (TIA) or ischemic stroke are at increased risk of developing cognitive impairment in the subacute phase. At present, the effects of exercise on cognitive functioning following a TIA or stroke are not fully known. The purpose of this trial was to investigate the effect of exercise on global cognition.

METHODS

The MoveIT trial is a single-centre, observer-blinded, randomized controlled trial involving a 1-year exercise intervention consisting of a 12-week group exercise program, combined with three counselling visits to the physiotherapists over a 9-month period. The control group received standard care. The primary outcome was global cognitive functioning, assessed at one year, using the Montreal Cognitive Assessment (MoCA). Secondary outcomes included cardiorespiratory fitness, the cardiovascular profile, and attainment of secondary prevention targets, anxiety, depression and fatigue at one and two years.

RESULTS

The experimental group consisted of 60 patients, while the control group consisted of 59 patients. The mean age was 64.3 years and 41% were female. No between-group differences were found on global cognitive functioning (MD, 0.7 out of 30, 95% CI, - 0.2 to 1.6) or on secondary outcome measures at 12 months. The only significant between-group difference was found for fatigue, in favour of the experimental group at 12 months (MD, 0.6 out of 63, 95% CI, 0.1 to 1.1).

CONCLUSIONS

No benefit of this exercise intervention was found regarding global cognition. Future studies need to focus on optimizing rehabilitation strategies for this vulnerable group of patients.

TRIAL REGISTRATION

http://www.trialregister.nl . Unique identifier: NL3721 . Date first registration: 06-03-2013.

Effect of Physical Activity on Cognitive Impairment in Patients With Cerebrovascular Diseases: A Systematic Review and Meta-Analysis

Background and Purpose

This study investigates the effect of physical activity (PA) on cognition in patients with cerebrovascular disease and explored the maximum benefit of different PA characteristics.

Methods

Databases, such as Pubmed, Web of Science, Embase, and Cochrane Library, were searched from their inception to May 31, 2021. Standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated to generate a forest plot. In addition, subgroup analysis, moderation analysis, and regression analysis were performed to explore the possible adjustment factors.

Results

In total, 22 studies that met the criteria were included, demonstrating data from 1,601 participants. The results indicated that PA produced a positive effect on the global cognition for patients with cerebrovascular disease (SMD: 0.20 [95% CI: 0.12-0.27]), at the same time, PA training prominently improved executive function (SMD: 0.09 [95% CI: 0.00-0.17]) and working memory (SMD: 0.25 [95% CI: 0.10-0.40]). Furthermore, patients with baseline cognitive impairment received the greater benefit of PA on cognition (SMD: 0.24 [95% CI: 0.14-0.34]) than those without cognitive impairment before intervention (SMD: 0.15 [95% CI: 0.04-0.26]). For patients in the acute stage (≤ 3 months), PA did not rescue impairment dysfunction significantly (SMD: 0.08 [95% CI: -0.04-0.21]) and remarkable cognitive gains were detected in the chronic stage of participants (>3 months) (SMD: 0.25 [95% CI: 0.16-0.35]). Moderate intensity PA showed a larger pooled effect size (SMD: 0.23 [95% CI: 0.11-0.36]) than low intensity (SMD: -0.01 [95% CI: -0.44-0.43]) and high intensity (SMD: 0.16 [95% CI: 0.03-0.29]). However, the different types, duration, and frequency of PA resulted in no differences in the improvement of cognitive function. Further regression analysis demonstrated that the beneficial effects of PA on cognition are negatively correlated with age (p < 0.05).

Conclusions

This study revealed that PA can prominently improve the cognitive ability in patients with cerebrovascular diseases and strengthened the evidence that PA held promise as a widely accessible and effective non-drug therapy for vascular cognitive impairment (VCI).

The process of commitment to exercise among stroke survivors in Canada

The objective of this research was to understand the process of commitment to exercise participation for functional recovery among community-living survivors of stroke following discharge from formal rehabilitation. Participants were recruited from a mid-sized city in south-western Ontario, Canada. Between September 2017 and March 2018, 10 individuals living in the community with the effects of stroke, who continued to engage in regular exercise post-stroke, were recruited for participation. Constructivist grounded theory methodology was employed, utilising in-depth individual interviews and theoretical sampling, whereby data collection and analysis occurred simultaneously. Analysis involved constant comparison between data and codes to reduce knowledge gaps and formulate the proposed theory. The process of commitment to exercise involved four phases. Initiation of the process followed a significant interaction with a healthcare provider who advocated for participants to learn the foundations of exercise. Through planned exercise, maintenance of a positive attitude and comparisons with their pre-stroke selves and peers, participants identified future goals and imparted the desire to get back to life before stroke. Over time individuals navigated exercise opportunities-trialling different types and environments-to learn what works. Finally, participants developed a commitment to exercise as a way of life, supported by social connections and reinforced with pride in successes-mastering self-care skills, improved mobility and meaningful function. The process of commitment to exercise among survivors of stroke required early interactions with healthcare providers to initiate exercise participation for long-term engagement, and navigation through various exercise elements fuelled by a desire to reconnect with their pre-stroke selves.

The Combined Influences of Exercise, Diet and Sleep on Neuroplasticity

Neuroplasticity refers to the brain's ability to undergo structural and functional adaptations in response to experience, and this process is associated with learning, memory and improvements in cognitive function. The brain's propensity for neuroplasticity is influenced by lifestyle factors including exercise, diet and sleep. This review gathers evidence from molecular, systems and behavioral neuroscience to explain how these three key lifestyle factors influence neuroplasticity alone and in combination with one another. This review collected results from human studies as well as animal models. This information will have implications for research, educational, fitness and neurorehabilitation settings.

Cognitive and Linguistic Benefits of Aerobic Exercise: A State-of-the-Art Systematic Review of the Stroke Literature

This systematic review aimed to determine how aerobic exercise affects cognition after stroke, with particular focus on aphasia and language improvement. Methodological quality was assessed with the PEDro+ scale with half of the 27 included studies rated as high quality. Data extraction focused on cognitive effects of aerobic exercise post-stroke, intervention characteristics, outcome measures, and participant characteristics. Whereas attention, memory, and executive functioning measures were common across the included studies, no study included a language-specific, performance-based measure. Seventeen studies reported positive cognitive effects, most frequently in the domains of attention, memory and executive functioning. Variability in outcome measures, intervention characteristics, and participant characteristics made it difficult to identify similarities among studies reporting positive cognitive effects of exercise or among those studies reporting null outcomes. Only three studies provided specific information about the number of individuals with aphasia included or excluded, who comprise approximately one-third of the stroke population. The review identified patent gaps in our understanding of how aerobic exercise may affect not only the cognitive domain of language post-stroke but also the broader cognitive functioning of individuals with post-stroke aphasia. Methodological limitations of the reviewed studies also warrant further examination of the direct impact of aerobic exercise on cognition post-stroke with careful attention to the selection and reporting of population, intervention, and outcomes.

Associations Between Time After Stroke and Exercise Training Outcomes: A Meta-Regression Analysis

Background Knowledge gaps exist regarding the effect of time elapsed after stroke on the effectiveness of exercise training interventions, offering incomplete guidance to clinicians. Methods and Results To determine the associations between time after stroke and 6-minute walk distance, 10-meter walk time, cardiorespiratory fitness and balance (Berg Balance Scale score [BBS]) in exercise training interventions, relevant studies in post-stroke populations were identified by systematic review. Time after stroke as continuous or dichotomized (≤3 months versus >3 months, and ≤6 months versus >6 months) variables and weighted mean differences in postintervention outcomes were examined in meta-regression analyses adjusted for study baseline mean values (pre-post comparisons) or baseline mean values and baseline control-intervention differences (controlled comparisons). Secondary models were adjusted additionally for mean age, sex, and aerobic exercise intensity, dose, and modality. We included 148 studies. Earlier exercise training initiation was associated with larger pre-post differences in mobility; studies initiated ≤3 months versus >3 months after stroke were associated with larger differences (weighted mean differences [95% confidence interval]) in 6-minute walk distance (36.3 meters; 95% CI, 14.2-58.5), comfortable 10-meter walk time (0.13 m/s; 95% CI, 0.06-0.19) and fast 10-meter walk time (0.16 m/s; 95% CI, 0.03-0.3), in fully adjusted models. Initiation ≤3 months versus >3 months was not associated with cardiorespiratory fitness but was associated with a higher but not clinically important Berg Balance Scale score difference (2.9 points; 95% CI, 0.41-5.5). In exercise training versus control studies, initiation ≤3 months was associated with a greater difference in only postintervention 6-minute walk distance (baseline-adjusted 27.3 meters; 95% CI, 6.1-48.5; fully adjusted, 24.9 meters; 95% CI, 0.82-49.1; a similar association was seen for ≤6 months versus >6 months after stroke (fully adjusted, 26.6 meters; 95% CI, 2.6-50.6). Conclusions There may be a clinically meaningful benefit to mobility outcomes when exercise is initiated within 3 months and up to 6 months after stroke.

Possible Engagement of Nicotinic Acetylcholine Receptors in Pathophysiology of Brain Ischemia-Induced Cognitive Impairment

Post-stroke disabilities like cognitive impairment impose are complex conditions with great economic burdens on health care systems. For these comorbidities, no effective therapies have been identified yet. Nicotinic acetylcholine receptors (nAChRs) are multifunctional receptors participating in various behavioral and neurobiological functions. During brain ischemia, the increased glutamate accumulation leads to neuronal excitotoxicity as well as mitochondrial dysfunction. These abnormalities then cause the increased levels of oxidants, which play key roles in neuronal death and apoptosis in the infarct zone. Additionally, recall of cytokines and inflammatory factors play a prominent role in the exacerbation of ischemic injury. As well, neurotrophic factors' insufficiency results in synaptic dysfunction and cognitive impairments in ischemic brain. Of note, nAChRs through various signaling pathways can participate in therapeutic approaches such as cholinergic system's stimulation, and reduction of excitotoxicity, inflammation, apoptosis, oxidative stress, mitochondrial dysfunction, and autophagy. Moreover, the possible roles of nAChRs in neurogenesis, synaptogenesis, and stimulation of neurotrophic factors expression have been reported previously. On the other hand, the majority of the above-mentioned mechanisms were found to be common in both brain ischemia pathogenesis and cognitive function tuning. Therefore, it seems that nAChRs might be known as key regulators in the control of ischemia pathology, and their modulation could be considered as a new avenue in the multi-target treatment of post-stroke cognitive impairment.

The influence of low-impact dance intervention on bone metabolism, cognition, and function fitness of old women

This study examined the low-impact dance intervention on the markers of bone metabolism, cognitive function, and functional fitness of postmenopausal women. Senior women were randomized into low-impact dance (LG) or control group (CG). Three dance sessions weekly were scheduled in the LG for 16 weeks. The markers of bone metabolism, bone composition, Stroop test, and functional fitness were assessed at pre- and post-intervention. The marker of bone formation, some of cognitive function and functional fitness were improved in the LG. The low-impact dance intervention benefited the marker of bone formation, parts of cognitive function and functional fitness.

Effects of Aerobic Exercise on Tau and Related Proteins in Rats with Photochemically-Induced Infarction

BACKGROUND

Recent evidence indicates brain ischemia is associated with accumulations of abnormal tau and related proteins. However, the effects of aerobic training on these proteins have not been evaluated.

OBJECTIVE

We aimed to evaluate the effect of aerobic exercise on the phosphorylation and acetylation of tau and on the expressions of tau related proteins in a rat stroke model and to compare the effects of aerobic exercise with those observed in our previous study on task specific training (TST).

METHODS

Twenty-four Sprague- Dawley rats with photothrombotic cortical infarction were used in the current study. The rehabilitation group (RG) received treadmill training 40 min/day for 28 days, whereas the sedentary group (SG) did not receive any type of training. Functional tests such as the single pellet reaching task, rotarod, and radial arm maze tests were performed weekly for 4 weeks post-infarction.

RESULTS

Levels of p-taus396 and p-AMPK were found to be lower in ipsilateral cortices in the RG than in the SG (p < 0.05). Levels of p-taus262, Ac-tau, p-GSK3βS9, p-Akt, p-Sin1, and p-P70-S6K were significantly lower in ipsilateral than in contralateral cortices in the RG (p < 0.05). Aerobic training also improved motor, balance, and memory functions.

CONCLUSION

Aerobic training inhibited the phosphorylation and acetylation of tau and modulated the expressions of tau related proteins after stroke by modifying the p70-S6K pathway and p-AMPK. By comparison with our previous study on the effects of TST, we have evidence to suggest that TST and aerobic exercise differ, although both types of rehabilitation inhibit tau phosphorylation and acetylation.

Effects of Combined Interventions with Aerobic Physical Exercise and Cognitive Training on Cognitive Function in Stroke Patients: A Systematic Review

(1) Background: Stroke is a major cause of permanent disability in multiple functions, including the cognitive domain. Since both cognitive training and aerobic physical exercise may exert positive effects on cognition after stroke, one may expect synergistic benefits when combining both interventions. (2) Methods: We carried out a systematic search of studies testing, in adult stroke patients, whether structured aerobic exercise combined with cognitive training led to higher cognitive benefits than either of these interventions when applied singly, or than interventions not including aerobic exercise or cognitive training. (3) Results: Five fair-quality randomized controlled trials fulfilled the search criteria. Exercise intensity was moderate-vigorous and cognitive training was mainly computer-based. The studies were heterogeneous regarding the cognitive tests used, and for this reason, a meta-analysis was not performed. Only three studies included follow-up assessment. The combined intervention was associated with pre-post improvement in at least one cognitive test in all the studies, and with higher positive effects compared to other conditions (although statistical significance was not always reached) in four studies. (4) Conclusions: Further trials including a long-term follow-up and comprehensive neuropsychological testing should be undertaken to determine whether combined aerobic exercise and cognitive training leads to additive cognitive benefits after stroke.

Tai Chi for Chronic Illness Management: Synthesizing Current Evidence from Meta-Analyses of Randomized Controlled Trials

An umbrella review of systematic reviews and meta-analyses of randomized controlled trials (RCTs) was conducted to evaluate the existing evidence of Tai Chi as a mind-body exercise for chronic illness management. MEDLINE/PubMed and Embase databases were searched from inception until March 31, 2019, for meta-analyses of at least two RCTs that investigated health outcomes associated with Tai Chi intervention. Evidence of significant outcomes (P value < 0.05) was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This review identified 45 meta-analyses of RCTs and calculated 142 summary estimates among adults living with 16 types of chronic illnesses. Statistically significant results (P value < 0.05) were identified for 81 of the 142 outcomes (57.0%), of which 45 estimates presenting 30 unique outcomes across 14 chronic illnesses were supported by high (n = 1) or moderate (n = 44) evidence. Moderate evidence suggests that Tai Chi intervention improved physical functions and disease-specific outcomes compared with nonactive controls and improved cardiorespiratory fitness compared with active controls among adults with diverse chronic illnesses. Between-study heterogeneity and publication bias were observed in some meta-analyses.

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.

Impact of aerobic exercise on cognitive function in patients with schizophrenia during daily nursing: A protocol for systematic review and meta-analysis

OBJECTIVES

To assess the effect of aerobic exercise (AE) on cognition function in people with schizophrenia (SZ) during daily nursing.

METHODS

The literature search will be conducted via PubMed, Embase, Cochrane Library, and Web of Science. Weighted mean difference (WMD) or standardized mean difference (SMD) and 95% confidence intervals (CIs) will be adopted to calculate the association between AE and cognitive function in patients with SZ. Publication bias will be performed by Begg test. When there is publication bias, "cut-and-fill method" will be adopted to adjust publication bias. Sensitivity analysis will be used to test the stability of the result. When the heterogeneity is large (I2 ≥ 50%), meta regression will be used to explore the source of inter-study heterogeneity. When the heterogeneity is large (I2 ≥ 50%) and the results are statistically significant (P < .05), age, sex, duration of disease, duration of intervention, amount of exercise per week, improvement of cardiopulmonary health, and other factors will be sub-analyzed.

CONCLUSION

This meta-analysis will evaluate the impact of aerobic exercise on cognitive function in patients with SZ during daily nursing on the basis of existing evidence.

OSF REGISTRATION NUMBER

10.17605/OSF.IO/C8ABX.

Preventive Approaches for Post-Stroke Depression: Where Do We Stand? A Systematic Review

PURPOSE

Post-stroke depression (PSD) occurs in one-third of stroke survivors, leading to a substantial decrease in quality of life as well as delayed functional and neurological recovery. Early detection of patients at risk and initiation of tailored preventive measures may reduce the medical and socioeconomic burden associated with PSD. We sought to review the current evidence on pharmacological and non-pharmacological prevention of PSD.

MATERIALS AND METHODS

We conducted a systematic review using PubMed/MEDLINE and bibliographies of identified papers following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including randomized controlled studies. Eligible studies were included when performed within 1 year after the index cerebrovascular event. Animal and basic research studies, studies lacking a control group, review papers, and case reports were excluded.

RESULTS

Out of 150 studies screened, 37 met our criteria. Among the strategies identified, administration of antidepressants displayed the most robust evidence for preventing PSD, whereas non-pharmacological interventions such as psychotherapy appear to be the most frequently used approaches to prevent depression after stroke. Research suggests that the efficacy of PSD prevention increases with the duration of preventive treatment. Seven out of 11 studies (63%) that used pharmacological and eight out of 16 (50%) that used non-pharmacological interventions reported a positive preventive effect on PSD.

CONCLUSION

Overall, the current literature on PSD prevention shows heterogeneity, substantiating a need for well-designed randomized controlled trials to test the safety and efficacy of pharmacological as well as non-pharmacological and composite prevention regimens to minimize the risk of PSD in stroke survivors. Integrative strategies combining personalized non-pharmacological interventions such as educational, mental, and physical health support, and pharmacological strategies such as SSRIs may be the most promising approach to prevent PSD.

Effects of Acute Aerobic Exercise Combined with Resistance Exercise on Neurocognitive Performance in Obese Women

To the best of the author’s knowledge, there have been no previous studies conducted on the effects of a combination of acute aerobic and resistance exercise on deficit of inhibitory control in obese individuals. The aim of this study was, thus, to examine the effect of a single bout of such an exercise mode on behavioral and cognitive electrophysiological performance involving cognitive interference inhibition in obese women. After the estimated VO₂max and percentage fat (measured with dual-energy X-ray absorptiometry (Hologic, Bedford, MA, USA) were assessed, 32 sedentary obese female adults were randomly assigned to an exercise group (EG) and a control group (CG), with their behavioral performance being recorded with concomitant electrophysiological signals when performing a Stroop task. Then, the EG engaged in 30 min of moderate-intensity aerobic exercise combined with resistance exercise, and the CG rested for a similar duration of time without engaging in any type of exercise. After the interventions, the neurocognitive performance was measured again in the two groups. The results revealed that although acute exercise did not enhance the behavioral indices (e.g., accuracy rates (ARs) and reaction times (RTs)), cognitive electrophysiological signals were improved (e.g., shorter N2 and P3 latencies, smaller N2 amplitudes, and greater P3 amplitudes) in the Stroop task after the exercise intervention in the EG. The findings indicated that a combination of acute moderate-intensity aerobic and resistance exercise may improve the neurophysiological inhibitory control performance of obese women.

Aerobic exercise attenuates neurodegeneration and promotes functional recovery - Why it matters for neurorehabilitation & neural repair

Aerobic exercise facilitates optimal neurological function and exerts beneficial effects in neurologic injuries. Both animal and clinical studies have shown that aerobic exercise reduces brain lesion volume and improves multiple aspects of cognition and motor function after stroke. Studies using animal models have proposed a wide range of potential molecular mechanisms that underlie the neurological benefits of aerobic exercise. Furthermore, additional exercise parameters, including time of initiation, exercise dosage (exercise duration and intensity), and treatment modality are also critical for clinical application, as identifying the optimal combination of parameters will afford patients with maximal functional gains. To clarify these issues, the current review summarizes the known neurological benefits of aerobic exercise under both physiological and pathological conditions and then considers the molecular mechanisms underlying these benefits in the contexts of stroke-like focal cerebral ischemia and cardiac arrest-induced global cerebral ischemia. In addition, we explore the key roles of exercise parameters on the extent of aerobic exercise-induced neurological benefits to elucidate the optimal combination for aerobic exercise intervention. Finally, the current challenges for aerobic exercise implementation after stroke are discussed.

Osteocalcin, ovarian senescence, and brain health

Menopause, an inevitable event in a woman's life, significantly increases risk of bone resorption and diseases such as Alzheimer's, vascular dementia, cardiac arrest, and stroke. The sole role of bones, as traditionally regarded, is to provide structural support for skeletal muscles and allow for ambulation, however this concept is becoming quickly outdated. New literature has emerged that suggests the bone cell-derived hormone osteocalcin (OCN) plays a pivotal role in cognition. OCN levels are correlated with bone mass density and bone turnover, and thus are strongly influenced by the changes associated with menopause. The goal of the current review is to discuss potential gaps in our knowledge of OCN and cognition, discrepancies in methods of OCN quantification, and therapies to enhance circulating OCN. A discussion on implementing exercise or low frequency vibration interventions at the menopausal transition to reduce risk and severity of neurological diseases and associated cognitive decline is included.

Including Patients With Stroke in Cardiac Rehabilitation: BARRIERS AND FACILITATORS

More than 13 million cases of stroke are occurring annually worldwide. Approximately a quarter of these strokes are recurrent strokes, and there is compelling evidence of the benefit of supervised exercise and risk factor modification programming in the secondary prevention of these strokes. However, there is insufficient time in inpatient and outpatient stroke rehabilitation for focused exercise interventions. General lifestyle interventions on their own, without guidance and supervision, are insufficient for improving physical activity levels. Cardiac rehabilitation (CR) is a setting where cardiac patients, and increasingly stroke patients, receive comprehensive secondary prevention programming, including structured exercise. Unfortunately, not all CR programs accept referrals for people following a stroke and for those that do, only a few patients participate. Therefore, the purpose of this review is to report the barriers and facilitators to improving linkage between health services, with a focus on increasing access to CR. In the next two decades, it is projected that there will be a marked increase in stroke prevalence globally. Therefore, there is an urgent need to create cross-program collaborations between hospitals, outpatient stroke rehabilitation, CR, and community programs. Improving access and removing disparities in access to evidence-based exercise treatments would positively affect the lives of millions of people recovering from stroke.

Effect of aerobic exercise on post-stroke cognitive function: a systematic review

Background/Aims

Literature suggests that aerobic exercise improves cognitive impairments post stroke. This systematic review was conducted to analyse evidence on the effectiveness of aerobic exercise in improving post-stroke cognitive impairments.

Methods

Online databases (PubMed, EMBASE and Web of Science) were systematically searched from inception until 13 July 2017 using the keywords stroke/exercise/cognition. Clinical trials that met the inclusion criteria were assessed for methodological quality using the PEDro scale. Extracted data were synthesised for evidence.

Results

A total of seven studies met the inclusion criteria. Participants in most of the studies were aged over 60 years and the majority had ischaemic stroke. The most commonly used measure for assessing cognition was the Mini Mental State Examination. The majority of studies included moderate to high intensity exercise (50–70% of VO2max) for 30–60 minutes three to five times per week. There is moderate evidence that aerobic exercise enhances global cognitive function, attention and working memory. Evidence that aerobic exercise improves memory, levels of brain-derived neurotrophic factor and executive function is conflicting and limited.

Conclusions

Aerobic exercise is moderately effective in improving post-stroke cognitive impairments. More clinical trials are needed in view of the methodological limitations and paucity of existing studies.

Inclusion of People Poststroke in Cardiac Rehabilitation Programs in Canada: A Missed Opportunity for Referral

BACKGROUND

Evidence supports establishing a continuum of care from stroke rehabilitation (SR) to cardiac rehabilitation programs (CRPs). It is not known to what extent people poststroke are being integrated. This study aimed to determine the proportion of CRPs that accept referrals poststroke, barriers/facilitators, and eligibility criteria.

METHODS

A web-based questionnaire was sent to CRPs across Canada.

RESULTS

Of 160 questionnaires sent, 114 representatives (71%) of 130 CRPs responded. Of respondents, 65% (n = 74) reported accepting people with a diagnosis of stroke and doing so for a median of 11 years, 11 offering stroke-specific classes and an additional 6 planning inclusion. However, 62.5% of CRPs reported that < 11 patients participated in the last calendar year despite 88.5% reporting no limit to the number they could enroll. Among CRPs, 25% accepted only patients with concurrent cardiac diagnoses, living in the community (47.8%), and without severe mobility (70.1%), communication (80.6%), or cognitive (85.1%) deficits. The 2 most influential barriers and facilitators among all CRPs were funding and staffing. The fourth greatest barrier was lack of poststroke referrals, and third to sixth facilitators were SR/CRP collaboration to ensure appropriate referrals (third) and to increase referrals (sixth), toolkits for prescribing resistance (fourth), and aerobic training (fifth). CRP characteristics associated with accepting stroke were a hybrid program model, a medium program size, and having a falls prevention component.

CONCLUSIONS

Most CRPs accept patients poststroke, but few participate. Therefore, establishing SR/CRP partnerships to increase appropriate referrals, using a toolkit to help operationalize exercise components, and allocating funding/resources to CRPs may significantly increase access to secondary prevention strategies.

Effect of reactive balance training on physical fitness poststroke: study protocol for a randomised non-inferiority trial

INTRODUCTION

Regular exercise is essential in the chronic phase of stroke recovery for improving or maintaining function, and reducing the risk of a second stroke. To achieve these goals, multiple components of fitness should be targeted with poststroke exercise, including aerobic capacity, strength and balance. However, following the recommended frequency and duration of each component separately can take a long time and lead to fatigue in people with stroke. Therefore, finding types of exercise that target multiple components of fitness all together is valuable.Reactive balance training (RBT) is a novel type of exercise where individuals repeatedly lose their balance in order to practise balance reactions. When people do RBT, they increase their heart rate and exert forces with their leg muscles which could improve aerobic fitness and muscle strength, respectively. This means that RBT could have the potential to improve multiple components of fitness, simultaneously.

METHODS AND ANALYSIS

This is a randomised controlled non-inferiority trial with internal pilot study. Participants with chronic stroke will be randomly assigned to one of two groups: (1) RBT or (2) aerobic and strength training (AST). Participants in both groups will complete 1 hour of exercise, three times/week for 12 weeks. The primary objective is to determine the effect of RBT on aerobic capacity and knee muscles' strength. The secondary objective is to determine the effects of RBT and AST on balance control and balance confidence. We expect to find that RBT is superior to AST in terms of improving balance control and balance confidence, yet not inferior to AST in terms of its effects on aerobic capacity and strength.

ETHICS AND DISSEMINATION

Research ethics approval has been received. Results will be disseminated directly to study participants at the end of the trial, and to other stakeholders via publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04042961.

What does real-world walking mean to people with stroke? An interpretive descriptive study

Purpose: Understanding personal experiences of real-world walking for stroke survivors could assist clinicians to tailor interventions to their clients' specific needs. We explored the research questions: "What does real-world walking mean to people after stroke and how do they think it can be better?"Method: Using an Interpretive Descriptive methodology, we purposively sampled eight stroke survivors who reported difficulty walking in the real-world. We sought diversity on key participant characteristics. Participants were interviewed using a semi-structured guide. Data were analysed with thematic analysis.Results: Many found real-world walking, particularly in the outdoors, created opportunities for freedom from dependence and a visible step by step progress, which generated hope for future recovery. Conversely, when participants did not experience sufficient progress, they expressed negative emotions. Participants strove to overcome challenges to their walking goals using everyday routines, planning skills, and confidence building experiences to motivate themselves. They also drew on, and extended, social resources highlighting the relational aspects of real-world walking.Conclusions: Walking in their real-world provided a meaningful, desirable, but challenging goal for participants that required significant emotional effort. Successful progress in real-world walking builds confidence and hope and can contribute to psychological wellbeing by providing opportunities for successful mastery and social connectedness.IMPLICATIONS FOR REHABILITATIONReal-world settings can be unpredictable which makes walking in the real-world after stroke demanding.Positive experiences of walking in the real-world can provide significant psychological benefits to stroke survivors.Many survivors need to carefully concentrate on the act of walking in outdoor settings.Pre-planning routes, confidence-building experiences and developing daily routines may help patients overcome these challenges.

Cognitive Reserve as an Emerging Concept in Stroke Recovery

Stroke is a leading cause of death and disability. It is a complex and largely heterogeneous condition. Prognosis for variations in impairment and recovery following stroke continues to be challenging and inaccurate, highlighting the need to examine the influence of other currently unknown variables to better predict and understand interindividual differences in stroke impairment and recovery. The concept of "cognitive reserve," a feature of brain function said to moderate the relationship between brain pathology and clinical outcomes, might provide a partial explanation. This review discusses the potential significance of cognitive reserve in the context of stroke, with reference to reduced burden of disability poststroke, health promotion, intervention and secondary prevention of cognitive impairment, ease and challenges of translation into clinical practice, prognosis and prediction of recovery, and clinical decisions and trial stratification. Discussions from the review aim to encourage stroke clinicians and researchers to better consider the role of premorbid, lifestyle-related variables, such as cognitive reserve, in facilitating successful neurological outcomes and recovery following stroke.

Eligibility, Enrollment, and Completion of Exercise-Based Cardiac Rehabilitation Following Stroke Rehabilitation: What Are the Barriers?

BACKGROUND

People after stroke benefit from comprehensive secondary prevention programs including cardiac rehabilitation (CR), yet there is little understanding of eligibility for exercise and barriers to use.

OBJECTIVE

The aim of this study was to examine eligibility for CR; enrollment, adherence, and completion; and factors affecting use.

DESIGN

This was a prospective study of 116 consecutive people enrolled in a single outpatient stroke rehabilitation (OSR) program located in Toronto, Ontario, Canada.

METHODS

Questionnaires were completed by treating physical therapists for consecutive participants receiving OSR and included reasons for CR ineligibility, reasons for declining participation, demographics, and functional level. CR eligibility criteria included the ability to walk ≥100 m (no time restriction) and the ability to exercise at home independently or with assistance. People with or without hemiplegic gait were eligible for adapted or traditional CR, respectively. Logistic regression analyses were used to examine factors associated with use indicators.

RESULTS

Of 116 participants receiving OSR, 82 (70.7%) were eligible for CR; 2 became eligible later. Sixty (71.4%) enrolled in CR and 49 (81.7%) completed CR, attending 87.1% (SD = 16.6%) of prescribed sessions. The primary reasons for ineligibility included being nonambulatory or having poor ambulation (52.9%; 18/34 patients) and having severe cognitive deficits and no home exercise support (20.6%; 7/34). Frequently cited reasons for declining CR were moving or travel out of country (17.2%; 5/29 reasons), lack of interest (13.8%; 4/29), transportation issues (10.3%; 3/29), and desiring a break from therapy (10.3%; 3/29). In a multivariate analysis, people who declined CR were more likely to be women, have poorer attendance at OSR, and not diabetic. Compared with traditional CR, stroke-adapted CR resulted in superior attendance (66.1% [SD = 22.9%] vs 87.1% [SD = 16.6%], respectively) and completion (66.7% vs 89.7%, respectively). The primary reasons for dropping out were medical (45%) and moving (27%).

LIMITATIONS

Generalizability to other programs is limited, and other, unmeasured factors may have affected outcomes.

CONCLUSIONS

An OSR-CR partnership provided an effective continuum of care, with approximately 75% of eligible people participating and more than 80% completing. However, just over 1 of 4 eligible people declined participation; therefore, strategies should target lack of interest, transportation, women, and people without diabetes. An alternative program model is needed for people who have severe ambulatory or cognitive deficits and no home exercise support.

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.

Combined Aerobic and Resistance Training for Cardiorespiratory Fitness, Muscle Strength, and Walking Capacity after Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Cardiorespiratory fitness, measured as peak oxygen consumption, is a potent predictor of stroke risk. Muscle weakness is the most prominent impairment after stroke and is directly associated with reduced walking capacity. There is a lack of recommendations for optimal combined aerobic training and resistance training for those patients. The purpose of this study was to systematically review and quantify the effects of exercise training on cardiorespiratory fitness, muscle strength, and walking capacity after stroke.

METHODS

Five electronic databases were searched (until May 2019) for studies that met the following criteria: (1) adult humans with a history of stroke who ambulate independently; (2) structured exercise intervention based on combined aerobic training and resistance training; and (3) measured cardiorespiratory fitness, muscle strength, and/or walking capacity.

RESULTS

Eighteen studies (602 participants, average age 62 years) met the inclusion criteria. Exercise training significantly improved all 3 outcomes. In subgroup analyses for cardiorespiratory fitness, longer training duration was significantly associated with larger effect size. Likewise, for muscle strength, moderate weekly frequency and lower training volume were significantly associated with larger effect size. Furthermore, in walking capacity, moderate weekly frequency and longer training duration were significantly associated with larger effect size.

CONCLUSIONS

These results suggest that an exercise program consisting of moderate-intensity, 3 days per week, for 20 weeks should be considered for greater effect on cardiorespiratory fitness, muscle strength, and walking capacity in stroke patients.

Sex-Dependent Differences in Physical Exercise-Mediated Cognitive Recovery Following Middle Cerebral Artery Occlusion in Aged Rats

Stroke remains a leading cause of death and disability in the United States. No current treatments exist to promote cognitive recovery in survivors of stroke. A previous study from our laboratory determined that an acute bout of forced treadmill exercise was able to promote cognitive recovery in 3 month old male rats after middle cerebral artery occlusion (MCAo). In this study, we tested the hypothesis that 6 days of intense acute bout of forced treadmill exercise (physical exercise – PE) promotes cognitive recovery in 11–14 month old male rats. We determined that PE was able to ameliorate cognitive deficits as determined by contextual fear conditioning. Additionally, we also tested the hypothesis that PE promotes cognitive recovery in 11–13 month old reproductive senescent female rats. In contrast to males, the same intensity of exercise that decrease cognitive deficits in males was not able to promote cognitive recovery in female rats. Additionally, we determined that exercise did not lessen infarct volume in both male and female rats. There are many factors that contribute to higher stroke mortality and morbidities in women and thus, future studies will investigate the effects of PE in aged female rats to identify sex differences.

Aerobic Training in Canadian Stroke Rehabilitation Programs

BACKGROUND AND PURPOSE

Aerobic training (AT) is recommended for people after stroke, yet uptake and operationalization of AT in clinical practice in Canada have not been measured. We surveyed inclusion of structured AT and barriers to implementation in public inpatient/outpatient stroke rehabilitation programs across Canada.

METHODS

A Web-based questionnaire was sent to 89 stroke rehabilitation program leads.

RESULTS

Forty-six programs from 7 of 9 eligible Canadian provinces/territories completed the questionnaire. Seventy-eight percent of programs reported including AT, with most (75%) excluding participants with severe physical impairments, and 28% excluding those with coexisting cardiac conditions. A greater proportion of dedicated stroke rehabilitation programs prescribed AT, compared to nondedicated stroke units (68.8% vs 31.3%, P = 0.02). The top 2 challenges for programs that included and did not include AT were "insufficient time within therapy sessions" and "length of stay in rehabilitation." Programs that did not include AT ranked "not a goal of most patients" and "not an organizational/program priority" as third and fourth, whereas they were ranked eighth and thirteenth by programs with AT. Best practice recommendations were inconsistently followed for conducting preparticipation exercise testing (36.1%) and for monitoring patients from higher-risk populations, specifically people with diabetes at risk for hypoglycemia (78.8%) and hypertension (36.6%). Of programs conducting preparticipation exercise testing, 91% did not monitor electrocardiography.

DISCUSSION AND CONCLUSIONS

Most stroke rehabilitation programs across Canada include AT. People with severe physical impairment and those with cardiac, metabolic, and hemodynamic comorbidities may be excluded or not appropriately monitored during exercise. More detailed guidelines and training practices are needed to address these challenges.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A233).

Trend of the burden of chronic illnesses: using the Canadian Community Health Survey

OBJECTIVES

Burden of illnesses has been described in the literature using the health-related quality of life (HRQoL) in people with chronic conditions. However, the studies reporting trends of burden are sparse. The aim of this study was to explore the trends of burden of chronic illness from the perspective of HRQoL.

STUDY DESIGN

This was a secondary analysis of administrative database.

METHODS

Seven data sets of the Canadian Community Health Survey from 2001 to 2014 were obtained for the analysis. Multiple linear and logistic regression models were used on each data set to assess the burden of illness on the Health Utilities Index Mark III (HUI₃), life satisfaction (LS), and perceived health (PH).

RESULTS

People with the effect of stroke constantly had low scores on the HUI₃, LS, and PH. Regression analyses revealed that arthritis, back problem, and mood disorder have greater impact on the HUI₃ score. Effect of stroke, mood disorder, and anxiety disorder stably had the largest negative impact on LS, while chronic obstructive pulmonary disease (COPD), effect of stroke, and cancer had the largest effect on PH.

CONCLUSION

This study identified that arthritis, back pain, mood disorder, effect of stroke, and COPD constantly have high burden on health outcomes compared with other chronic condition over the past decade.

Exercise as a prescription for patients with various diseases

A growing understanding of the benefits of exercise over the past few decades has prompted researchers to take an interest in the possibilities of exercise therapy. Because each sport has its own set of characteristics and physiological complications that tend to occur during exercise training, the effects and underlying mechanisms of exercise remain unclear. Thus, the first step in probing the effects of exercise on different diseases is the selection of an optimal exercise protocol. This review summarizes the latest exercise prescription treatments for 26 different diseases: musculoskeletal system diseases (low back pain, tendon injury, osteoporosis, osteoarthritis, and hip fracture), metabolic system diseases (obesity, type 2 diabetes, type 1 diabetes, and nonalcoholic fatty liver disease), cardio-cerebral vascular system diseases (coronary artery disease, stroke, and chronic heart failure), nervous system diseases (Parkinson's disease, Huntington's disease, Alzheimer's disease, depression, and anxiety disorders), respiratory system diseases (chronic obstructive pulmonary disease, interstitial lung disease, and after lung transplantation), urinary system diseases (chronic kidney disease and after kidney transplantation), and cancers (breast cancer, colon cancer, prostate cancer, and lung cancer). Each exercise prescription is displayed in a corresponding table. The recommended type, intensity, and frequency of exercise prescriptions are summarized, and the effects of exercise therapy on the prevention and rehabilitation of different diseases are discussed.

A systematic review and meta-analysis of the effects of cardiac rehabilitation interventions on cognitive impairment following stroke

PURPOSE

The cardiac rehabilitation model has potential as an approach to providing rehabilitation following stroke. This review aims to identify evidence for the participation of stroke patients in cardiac/cardiovascular rehabilitation programs internationally, whether or not such programs offer a cognitive intervention as part of treatment, and the impact of rehabilitation on post-stroke cognitive function.

METHOD

Five electronic databases were searched from inception to 1 May 2019, namely: MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Central Register of Controlled Trials, and the Web of Science. Eligible studies included both randomized and non-randomized studies of cardiac rehabilitation-type interventions which measured cognitive function in patients with transient ischemic attack (TIA) or stroke.

RESULTS

Of 14,153 records reviewed, nine studies which delivered cardiac rehabilitation-type interventions to stroke patients were finally included. Only three of these studies delivered cognitive rehabilitation as part of the intervention. Cardiac rehabilitation had no statistically significant effect on cognitive function in five randomized controlled trials (standardized mean difference= 0.28, 95% CI= -0.16 to 0.73) or in three one group pre-post studies (standardized mean difference= 0.15, 95% CI= -0.03 to 0.33).

CONCLUSIONS

This review highlights that there are very few studies of delivery of cardiac rehabilitation to stroke patients and that the inclusion of cognitive interventions is even less common, despite the high prevalence of post-stroke cognitive impairment.IMPLICATIONS FOR REHABILITATIONThe cardiac rehabilitation model has the potential to be expanded to include patients post-stroke given the commonality of secondary prevention needs, thereby becoming a cardiovascular rehabilitation model.Up to half of patients experience cognitive impairment after stroke; suggesting that a post-stroke cardiovascular rehabilitation model should incorporate specific cognitive strategies for patients.This systematic review identified three cardiovascular rehabilitation programmes which delivered cognitive rehabilitation as part of treatment; however, evidence for efficacy is weak.

Functional and/or structural brain changes in response to resistance exercises and resistance training lead to cognitive improvements - a systematic review

BACKGROUND

During the aging process, physical capabilities (e.g., muscular strength) and cognitive functions (e.g., memory) gradually decrease. Regarding cognitive functions, substantial functional (e.g., compensatory brain activity) and structural changes (e.g., shrinking of the hippocampus) in the brain cause this decline. Notably, growing evidence points towards a relationship between cognition and measures of muscular strength and muscle mass. Based on this emerging evidence, resistance exercises and/or resistance training, which contributes to the preservation and augmentation of muscular strength and muscle mass, may trigger beneficial neurobiological processes and could be crucial for healthy aging that includes preservation of the brain and cognition. Compared with the multitude of studies that have investigated the influence of endurance exercises and/or endurance training on cognitive performance and brain structure, considerably less work has focused on the effects of resistance exercises and/or resistance training. While the available evidence regarding resistance exercise-induced changes in cognitive functions is pooled, the underlying neurobiological processes, such as functional and structural brain changes, have yet to be summarized. Hence, the purpose of this systematic review is to provide an overview of resistance exercise-induced functional and/or structural brain changes that are related to cognitive functions.

METHODS AND RESULTS

A systematic literature search was conducted by two independent researchers across six electronic databases; 5957 records were returned, of which 18 were considered relevant and were analyzed.

SHORT CONCLUSION

Based on our analyses, resistance exercises and resistance training evoked substantial functional brain changes, especially in the frontal lobe, which were accompanied by improvements in executive functions. Furthermore, resistance training led to lower white matter atrophy and smaller white matter lesion volumes. However, based on the relatively small number of studies available, the findings should be interpreted cautiously. Hence, future studies are required to investigate the underlying neurobiological mechanisms and to verify whether the positive findings can be confirmed and transferred to other needy cohorts, such as older adults with dementia, sarcopenia and/or dynapenia.