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Sutton KM, Hunter EG, Logsdon B, Santella B, Kitzman PH. The Role of Physical Therapy in Multiple Risk Factor Management Poststroke: A Scoping Review. J Geriatr Phys Ther 2020; 44:165-174. [PMID: 32511115 DOI: 10.1519/jpt.0000000000000248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Individuals after stroke often have multiple chronic conditions, such as hypertension, diabetes, dyslipidemia, obesity, and tobacco use. These comorbidities not only are commonly found in individuals with stroke, but also negatively affect functional outcomes and increase risk for hospital readmission and overall mortality. It is important for physical therapists to address the whole person during treatment after stroke, including comorbidities, not just the problems resulting from the stroke itself. However, it is unclear how common it is for physical therapists to address multiple diagnoses at once using a wellness model. Therefore, the purpose of this scoping review was to examine current evidence regarding the role of physical therapy in addressing modifiable risk factors for individuals after stroke, to identify gaps in research associated with physical therapy management of related comorbid diagnoses during treatment for stroke. METHODS A scoping review methodology was utilized searching PubMed and CINAHL databases to identify interventional research studies specifically addressing multiple modifiable risk factors utilizing physical therapy for individuals after stroke. RESULTS The initial search yielded 5358 articles and 12 articles met full inclusion criteria. Only 2 studies included participants with significant mobility impairments, and none included individuals with communication impairments. Only 4 of the 12 studies provided education in their design. Eight studies did not include any patient-reported outcome measures. Only 3 studies included long-term follow-up assessments. DISCUSSION Secondary stroke risk factors can be positively addressed using physical therapy interventions; however, more research is needed regarding individuals with moderate to severe mobility or communication deficits. Opportunities for physical therapy research to address stroke risk factors in this complex population include expanding follow-up periods, improving educational interventions, and including caregivers in study design. CONCLUSIONS This review highlights the need for better integration of clinical considerations into stroke rehabilitation research as a whole, along with the need for additional research regarding the role physical therapy can play in addressing multimorbidity in individuals with stroke.
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Affiliation(s)
| | | | - Brooke Logsdon
- Department of Physical Therapy, University of Kentucky, Lexington
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2
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Veldema J, Jansen P. Ergometer Training in Stroke Rehabilitation: Systematic Review and Meta-analysis. Arch Phys Med Rehabil 2020; 101:674-689. [DOI: 10.1016/j.apmr.2019.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/27/2019] [Indexed: 12/22/2022]
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Brouwer R, Wondergem R, Otten C, Pisters MF. Effect of aerobic training on vascular and metabolic risk factors for recurrent stroke: a meta-analysis. Disabil Rehabil 2019; 43:2084-2091. [PMID: 31794269 DOI: 10.1080/09638288.2019.1692251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIM This meta-analysis aimed to determine the effect of aerobic training, compared to non-aerobic interventions, on vascular and metabolic risk factors for recurrent stroke. METHOD This study was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines (PRISMA). Searches were performed in PubMed, Embase, Cochrane library and Cinahl up to May 8th 2019. Randomized clinical trials evaluating the effect of solely aerobic training on vascular and metabolic risk factors for recurrent stroke were included in a meta-analysis if relevant outcomes were reported in at least two articles. RESULTS Our search resulted in a total of 7381 hits. Eleven outcomes out of nine articles were included in the meta-analysis. A significant positive effect of aerobic training was found on systolic blood pressure (-3.59 mmHg, 95% CI -6.14 to -1.05) and fasting glucose (-0.12 mmol/l, 95% CI -0.23 to -0.02). The effect on systolic blood pressure further improved when only high-quality studies were included (-4.95 mmHg, 95% CI -8.24 to -1.66). CONCLUSION Aerobic training results in a significant positive effect on systolic blood pressure and fasting glucose after stroke when compared to non-aerobic usual care or non-aerobic exercise.Implications for rehabilitationAerobic training has a positive effect on two of the most important vascular risk factors for recurrent stroke (i.e., systolic blood pressure and fasting glucose).The effect of solely aerobic training seems to be comparable to the effect of combined strength exercise and aerobic training for systolic blood pressure and fasting glucose.Since aerobic training has a significant effect on risk factors for recurrent stroke, implementation of aerobic training in daily life is important to reduce long term stroke risk.Previous research has showed that other metabolic risk factors can be altered by other interventions (e.g., strength exercise or lifestyle coaching), therefore, post-stroke prevention programs should be tailored in order to target specific risk-factors for individual patients.
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Affiliation(s)
- Rafaël Brouwer
- Royal Dutch Society for Physical Therapy (KNGF), Amersfoort, the Netherlands.,Department of Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center, Utrecht, the Netherlands
| | - Roderick Wondergem
- Department of Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center, Utrecht, the Netherlands.,Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, the Netherlands.,Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands.,Department of Health Innovations and Technology, Fontys University of Applied Sciences, Eindhoven, the Netherlands
| | - Carlijn Otten
- Department of Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center, Utrecht, the Netherlands
| | - Martijn F Pisters
- Department of Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center, Utrecht, the Netherlands.,Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, the Netherlands.,Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands.,Department of Health Innovations and Technology, Fontys University of Applied Sciences, Eindhoven, the Netherlands
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Belfiore P, Miele A, Gallè F, Liguori G. Adapted physical activity and stroke: a systematic review. J Sports Med Phys Fitness 2018; 58:1867-1875. [DOI: 10.23736/s0022-4707.17.07749-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Lloyd M, Skelton DA, Mead GE, Williams B, van Wijck F. Physical fitness interventions for nonambulatory stroke survivors: A mixed-methods systematic review and meta-analysis. Brain Behav 2018; 8:e01000. [PMID: 29920979 PMCID: PMC6043697 DOI: 10.1002/brb3.1000] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/10/2018] [Accepted: 04/15/2018] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Physical fitness training after stroke is recommended in guidelines across the world, but evidence pertains mainly to ambulatory stroke survivors. Nonambulatory stroke survivors (FAC score ≤2) are at increased risk of recurrent stroke due to limited physical activity. This systematic review aimed to synthesize evidence regarding case fatality, effects, experiences, and feasibility of fitness training for nonambulatory stroke survivors. METHODS Eight major databases were searched for any type of study design. Two independent reviewers selected studies, extracted data, and assessed study quality, using published tools. Random-effects meta-analysis was used. Following their separate analysis, qualitative and quantitative data were synthesized using a published framework. RESULTS Of 13,614 records, 33 studies involving 910 nonambulatory participants met inclusion criteria. Most studies were of moderate quality. Interventions comprised assisted walking (25 studies), cycle ergometer training (5 studies), and other training (3 studies), mainly in acute settings. Case fatality did not differ between intervention (1.75%) and control (0.88%) groups (95% CI 0.13-3.78, p = 0.67). Compared with control interventions, assisted walking significantly improved: fat mass, peak heart rate, peak oxygen uptake and walking endurance, maximum walking speed, and mobility at intervention end, and walking endurance, balance, mobility, and independent walking at follow-up. Cycle ergometry significantly improved peak heart rate, work load, peak ventilation, peak carbon dioxide production, HDL cholesterol, fasting insulin and fasting glucose, and independence at intervention end. Effectiveness of other training could not be established. There were insufficient qualitative data to draw conclusions about participants' experiences, but those reported were positive. There were few intervention-related adverse events, and dropout rate ranged from 12 to 20%. CONCLUSIONS Findings suggest safety, effectiveness, and feasibility of adapted fitness training for screened nonambulatory stroke survivors. Further research needs to investigate the clinical and cost-effectiveness as well as experiences of fitness training-especially for chronic stroke survivors in community settings.
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Affiliation(s)
- Megan Lloyd
- School of Health and Life SciencesGlasgow Caledonian UniversityGlasgowUK
| | - Dawn A. Skelton
- School of Health and Life SciencesGlasgow Caledonian UniversityGlasgowUK
| | - Gillian E. Mead
- Geriatric MedicineDivision of Health SciencesCentre for Clinical Brain SciencesThe University of Edinburgh, and the Royal InfirmaryEdinburghUK
| | - Brian Williams
- School of Health and Social CareEdinburgh Napier UniversityEdinburghUK
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Wang C, Redgrave J, Shafizadeh M, Majid A, Kilner K, Ali AN. Aerobic exercise interventions reduce blood pressure in patients after stroke or transient ischaemic attack: a systematic review and meta-analysis. Br J Sports Med 2018; 53:1515-1525. [PMID: 29743171 DOI: 10.1136/bjsports-2017-098903] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Secondary vascular risk reduction is critical to preventing recurrent stroke. We aimed to evaluate the effect of exercise interventions on vascular risk factors and recurrent ischaemic events after stroke or transient ischaemic attack (TIA). DESIGN Intervention systematic review and meta-analysis. DATA SOURCES OVID MEDLINE, PubMed, The Cochrane Library, Web of Science, The National Institute for Health and Care Excellence, TRIP Database, CINAHL, PsycINFO, SCOPUS, UK Clinical Trials Gateway and the China National Knowledge Infrastructure were searched from 1966 to October 2017. ELIGIBILITY CRITERIA Randomised controlled trials evaluating aerobic or resistance exercise interventions on vascular risk factors and recurrent ischaemic events among patients with stroke or TIA, compared with control. RESULTS Twenty studies (n=1031) were included. Exercise interventions resulted in significant reductions in systolic blood pressure (SBP) -4.30 mm Hg (95% CI -6.77 to -1.83) and diastolic blood pressure -2.58 mm Hg (95% CI -4.7 to -0.46) compared with control. Reduction in SBP was most pronounced among studies initiating exercise within 6 months of stroke or TIA (-8.46 mm Hg, 95% CI -12.18 to -4.75 vs -2.33 mm Hg, 95% CI -3.94 to -0.72), and in those incorporating an educational component (-7.81 mm Hg, 95% CI -14.34 to -1.28 vs -2.78 mm Hg, 95% CI -4.33 to -1.23). Exercise was also associated with reductions in total cholesterol (-0.27 mmol/L, 95% CI -0.54 to 0.00), but not fasting glucose or body mass index. One trial reported reductions in secondary vascular events with exercise, but was insufficiently powered. SUMMARY Exercise interventions can result in clinically meaningful blood pressure reductions, particularly if initiated early and alongside education.
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Affiliation(s)
- Cheng Wang
- Faculty of Medicine Dentistry and Health, University of Sheffield, Sheffield, UK
| | - Jessica Redgrave
- Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Mohsen Shafizadeh
- Sheffield Hallam University, Academy of Sport and Physical Activity, Sheffield, UK
| | - Arshad Majid
- Faculty of Medicine Dentistry and Health, University of Sheffield, Sheffield, UK.,Sheffield NIHR Biomedical Research Centre, Sheffield, UK
| | - Karen Kilner
- Sheffield Hallam University, Centre for Health and Social Care Research, Sheffield, UK
| | - Ali N Ali
- Faculty of Medicine Dentistry and Health, University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Geriatrics and Stroke Medicine, Sheffield, UK
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Four birds with one stone? Reparative, neuroplastic, cardiorespiratory, and metabolic benefits of aerobic exercise poststroke. Curr Opin Neurol 2018; 29:684-692. [PMID: 27661010 DOI: 10.1097/wco.0000000000000383] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Ribeiro TS, Chaves da Silva TC, Carlos R, de Souza E Silva EMG, Lacerda MO, Spaniol AP, Lindquist ARR. Is there influence of the load addition during treadmill training on cardiovascular parameters and gait performance in patients with stroke? A randomized clinical trial. NeuroRehabilitation 2017; 40:345-354. [PMID: 28222556 DOI: 10.3233/nre-161422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although exercises involving both lower limbs are indicated for aerobic training, stroke patients have shown expressive asymmetry between the paretic and non-paretic lower limb (NPLL). Performing activities that stimulate the paretic limb during aerobic exercise may optimize training results. OBJECTIVE To evaluate if there is influence of load addition on NPLL during treadmill training on cardiovascular parameters and gait performance of subacute stroke patients. METHODS Thirty-eight stroke subjects with gait deficits were randomized into experimental group, which underwent treadmill training with a mass attached on NPLL, and control group, which underwent only treadmill training. Interventions lasted 2 weeks (9 sessions). Main outcomes were heart rate, arterial blood pressure, gait speed and distance covered. Assessments occurred at rest, 10th and 20th minutes of the session and immediately after each session. RESULTS There was improvement in speed and walking distance in both groups. All cardiovascular parameters had showed no changes compared to 1st and 9th sessions and there were no differences between groups within each session. CONCLUSIONS Load addition on NPLL did not alter cardiovascular parameters and gait training provide better gait performance of subacute stroke patients, which indicates this therapy can be considered useful and safe for these patients.
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D’Isabella NT, Shkredova DA, Richardson JA, Tang A. Effects of exercise on cardiovascular risk factors following stroke or transient ischemic attack: a systematic review and meta-analysis. Clin Rehabil 2017; 31:1561-1572. [DOI: 10.1177/0269215517709051] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Ada Tang
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
- Department of Kinesiology, McMaster University, Hamilton, ON, Canada
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Boyne P, Welge J, Kissela B, Dunning K. Factors Influencing the Efficacy of Aerobic Exercise for Improving Fitness and Walking Capacity After Stroke: A Meta-Analysis With Meta-Regression. Arch Phys Med Rehabil 2016; 98:581-595. [PMID: 27744025 DOI: 10.1016/j.apmr.2016.08.484] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/16/2016] [Accepted: 08/26/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the influence of dosing parameters and patient characteristics on the efficacy of aerobic exercise (AEX) poststroke. DATA SOURCES A systematic review was conducted using PubMed, MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Physiotherapy Evidence Database, and Academic Search Complete. STUDY SELECTION Studies were selected that compared an AEX group with a nonaerobic control group among ambulatory persons with stroke. DATA EXTRACTION Extracted outcome data included peak oxygen consumption (V˙o2peak) during exercise testing, walking speed, and walking endurance (6-min walk test). Independent variables of interest were AEX mode (seated or walking), AEX intensity (moderate or vigorous), AEX volume (total hours), stroke chronicity, and baseline outcome scores. DATA SYNTHESIS Significant between-study heterogeneity was confirmed for all outcomes. Pooled AEX effect size estimates (AEX group change minus control group change) from random effects models were V˙o2peak, 2.2mL⋅kg-1⋅min-1 (95% confidence interval [CI], 1.3-3.1mL⋅kg-1⋅min-1); walking speed, .06m/s (95% CI, .01-.11m/s); and 6-minute walk test distance, 29m (95% CI, 15-42m). In meta-regression, larger V˙o2peak effect sizes were significantly associated with higher AEX intensity and higher baseline V˙o2peak. Larger effect sizes for walking speed and the 6-minute walk test were significantly associated with a walking AEX mode. In contrast, seated AEX did not have a significant effect on walking outcomes. CONCLUSIONS AEX significantly improves aerobic capacity poststroke, but may need to be task specific to affect walking speed and endurance. Higher AEX intensity is associated with better outcomes. Future randomized studies are needed to confirm these results.
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Affiliation(s)
- Pierce Boyne
- Department of Rehabilitation Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio; Department of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
| | - Jeffrey Welge
- Department of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, Ohio; Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Brett Kissela
- Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Kari Dunning
- Department of Rehabilitation Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio; Department of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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Resistance Training Improves Hyperglycemia and Dyslipidemia, Highly Prevalent Among Nonelderly, Nondiabetic, Chronically Disabled Stroke Patients. Arch Phys Med Rehabil 2015; 96:1291-6. [DOI: 10.1016/j.apmr.2015.03.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 03/20/2015] [Accepted: 03/23/2015] [Indexed: 11/18/2022]
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12
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Imura T, Nagasawa Y, Inagawa T, Imada N, Izumi H, Emoto K, Tani I, Yamasaki H, Ota Y, Oki S, Maeda T, Araki O. Prediction of motor outcomes and activities of daily living function using diffusion tensor tractography in acute hemiparetic stroke patients. J Phys Ther Sci 2015; 27:1383-6. [PMID: 26157225 PMCID: PMC4483403 DOI: 10.1589/jpts.27.1383] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 01/11/2015] [Indexed: 12/13/2022] Open
Abstract
[Purpose] The efficacy of diffusion tensor imaging in the prediction of motor outcomes
and activities of daily living function remains unclear. We evaluated the most appropriate
diffusion tensor parameters and methodology to determine whether the region of interest-
or tractography-based method was more useful for predicting motor outcomes and activities
of daily living function in stroke patients. [Subjects and Methods] Diffusion tensor
imaging data within 10 days after stroke onset were collected and analyzed for 25
patients. The corticospinal tract was analyzed. Fractional anisotropy, number of fibers,
and apparent diffusion coefficient were used as diffusion tensor parameters. Motor
outcomes and activities of daily living function were evaluated on the same day as
diffusion tensor imaging and at 1 month post-onset. [Results] The fractional anisotropy
value of the affected corticospinal tract significantly correlated with the motor outcome
and activities of daily living function within 10 days post-onset and at 1 month
post-onset. Tthere were no significant correlations between other diffusion tensor
parameters and motor outcomes or activities of daily living function. [Conclusion] The
fractional anisotropy value of the affected corticospinal tract obtained using the
tractography-based method was useful for predicting motor outcomes and activities of daily
living function in stroke patients.
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Affiliation(s)
- Takeshi Imura
- Department of Rehabilitation, Araki Neurosurgical Hospital: 2-8-7 Kogokita, Hiroshima, Hiroshima, Japan
| | - Yuki Nagasawa
- Department of Rehabilitation, Araki Neurosurgical Hospital: 2-8-7 Kogokita, Hiroshima, Hiroshima, Japan
| | - Tetsuji Inagawa
- Department of Neurosurgery, Araki Neurosurgical Hospital, Japan
| | - Naoki Imada
- Department of Rehabilitation, Araki Neurosurgical Hospital: 2-8-7 Kogokita, Hiroshima, Hiroshima, Japan
| | - Hiroaki Izumi
- Department of Radiology, Araki Neurosurgical Hospital, Japan
| | - Katsuya Emoto
- Department of Neurosurgery, Araki Neurosurgical Hospital, Japan
| | - Itaru Tani
- Department of Neurosurgery, Araki Neurosurgical Hospital, Japan
| | | | - Yuichiro Ota
- Department of Neurosurgery, Araki Neurosurgical Hospital, Japan
| | - Shuichi Oki
- Department of Neurosurgery, Araki Neurosurgical Hospital, Japan
| | - Tadanori Maeda
- Department of Radiology, Araki Neurosurgical Hospital, Japan
| | - Osamu Araki
- Department of Neurosurgery, Araki Neurosurgical Hospital, Japan
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Rincón M. Prevention and Cardiac Rehabilitation Program: useful and necessary tool in the treatment after stroke. REVISTA COLOMBIANA DE CARDIOLOGÍA 2015. [DOI: 10.1016/j.rccar.2015.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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