Anna E. Mattlage

Aerobic Exercise in Subacute Stroke Improves Cardiovascular Health and Physical Performance

Background and Purpose: Cardiovascular health is often impaired after stroke. Reduced exercise capacity ( O2peak) and changes in the vascular system in the stroke-affected limb may impact performance of physical activities such as walking. There is little information regarding the role of prescribed moderate- to high-intensity exercise in subacute stroke. The purpose of this study was to examine whether an 8-week aerobic exercise intervention would improve cardiovascular health and physical performance in participants with subacute stroke. Methods: Ten subjects were enrolled in the study and 9 of them completed the intervention. Participants were aged 61.2 ± 4.7 years old, were 66.7 ± 41.5 days poststroke, and had minor motor performance deficits (Fugl-Meyer score, 100.3 ± 29.3). Outcome measures were taken at baseline, postintervention, and at 1-month follow-up. Brachial artery vasomotor reactivity (flow-mediated dilation [FMD]) of both arms was used to assess vascular health, and a peak exercise test was used to assess exercise capacity. The 6-minute walk test (6MWT) was used to assess physical performance. Participants exercised on a recumbent stepper 3 times per week for 8 weeks at a prescribed heart rate intensity. Results: At baseline, we identified between-limb differences in brachial artery FMD and low O2peak values. After the intervention, significant improvements were observed in the FMD in both arms, resting systolic blood pressure, and the 6MWT. Although we also observed improvements in the resting diastolic blood pressure, heart rate, and O2peak values, these changes were not significantly different. Discussion and Conclusion: Aerobic exercise in participants with subacute stroke was beneficial for improving cardiovascular health, reducing cardiac risk, and improving physical performance (6MWT). Video abstract available (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A29) for more insights from the authors.

Use of Accelerometers to Examine Sedentary Time on an Acute Stroke Unit

Background and Purpose: Observational studies demonstrate low levels of physical activity during inpatient stroke rehabilitation. There are no prior studies that have objectively measured sedentary time on the acute stroke unit and whether sedentary time is related to functional outcomes. The purpose of this study was to characterize sedentary time after acute stroke and determine whether there is a relationship to functional performance at discharge. Methods: Thirty-two individuals (18 men; 56.5 ± 12.7 years) with acute stroke were enrolled within 48 hours of hospital admission. An accelerometer was placed on the stroke-affected ankle to measure 24-hour activity and was worn for 4 days or until discharge from the hospital. Performance of activities of daily living, walking endurance, and functional mobility were assessed using the Physical Performance Test, Six-Minute Walk Test, and Timed Up and Go, respectively. Results: Mean percent time spent sedentary was 93.9 ± 4.1% and percent time in light activity was 5.1 ± 2.4%. When controlling for baseline performance, the mean time spent sedentary per day was significantly related to Physical Performance Test performance at discharge (r = −0.37; P = .05), but not the Six-Minute Walk Test or Timed Up and Go. Discussion and Conclusions: Patients with acute stroke were sedentary most of their hospital stay. To minimize the potential negative effects of inactivity, our data suggest that there should be greater emphasis on increasing physical activity during the hospital stay. Video Abstract Available for more insights from the authors (Supplemental Digital Content 1, http://links.lww.com/JNPT/A101).

Does Aerobic Exercise and the FITT Principle Fit into Stroke Recovery

Sedentary lifestyle after stroke is common which results in poor cardiovascular health. Aerobic exercise has the potential to reduce cardiovascular risk factors and improve functional capacity and quality of life in people after stroke. However, aerobic exercise is a therapeutic intervention that is underutilized by healthcare professionals after stroke. The purpose of this review paper is to provide information on exercise prescription using the FITT principle (frequency, intensity, time, type) for people after stroke and to guide healthcare professionals to incorporate aerobic exercise into the plan of care. This article discusses the current literature outlining the evidence base for incorporating aerobic exercise into stroke rehabilitation. Recently, high-intensity interval training has been used with people following stroke. Information is provided regarding the early but promising results for reaching higher target heart rates.

Cross-Validation of the Recumbent Stepper Submaximal Exercise Test to Predict Peak Oxygen Uptake in Older Adults

Background Submaximal exercise testing can have a greater application in clinical settings because peak exercise testing is generally not available. In previous work, a prediction equation was developed to estimate peak oxygen consumption (V̇o2) using a total body recumbent stepper (TBRS) and the Young Mens Christian Association (YMCA) protocol in adults who were healthy. Objective The purpose of the present study was to cross-validate the TBRS peak V̇o2 prediction equation in older adults. Design A cross-sectional study was conducted. Methods Thirty participants (22 female, 8 male; mean age=66.8 years, SD=5.52; mean weight=68.51 kg, SD=13.39) who previously completed a peak exercise test and met the inclusion criteria were invited to participate in the cross-validation study. Within 5 days of the peak V̇o2 test, participants completed the TBRS submaximal exercise test. The TBRS submaximal exercise test equation was used to estimate peak V̇o2. The variables in the equation included age, weight, sex, watts (at the end of the submaximal exercise test), and heart rate (at the end of the submaximal exercise test). Results A strong correlation was found between the predicted peak V̇o2 and the measured peak V̇o2. The difference between the values was 0.9 mL·kg−1·min−1, which was not statistically different. The standard error of the estimate was 4.2 mL·kg−1·min−1. Limitations The sample included individuals who volunteered to perform a peak exercise test, which may have biased the results toward those willing to exercise to fatigue. Conclusion The data suggest the TBRS submaximal exercise test and prediction equation can be used to predict peak V̇o2 in older adults. This finding is important for health care professionals wanting to provide information to their patients or clients regarding their fitness level.

Decrease in Insulin-Like Growth Factor-1 and Insulin-Like Growth Factor-1 Ratio in the First Week of Stroke Is Related to Positive Outcomes

BACKGROUND High insulin-like growth factor-1 (IGF-1), measured once during acute stroke, is associated with greater survival rates and lower stroke severity. However, information is lacking regarding how IGF-1 availability, determined by IGF-1s ratio to insulin-like growth factor binding protein-3 (IGFBP-3), relates to recovery and how the response of IGF-1 during the first week of stroke relates to outcomes. The purpose of this study was to determine the following: (1) the relationship between percent change in IGF-1 and IGF-1 ratio during the first week of stroke and stroke outcomes; and (2) the difference in percent change in IGF-1 and IGF-1 ratio in individuals being discharged home and individuals being discharged to inpatient facilities. METHODS IGF-1 and IGFBP-3 were quantified from blood sampled twice (<72 hours of admission; 1 week post stroke) in 15 individuals with acute stroke. Length of stay, modified Rankin Scale at 1 month, and discharge destination were obtained from electronic medical records. RESULTS Percent change in IGF-1 ratio was related to length of stay (r = .54; P = .04). Modified Rankin Scale (n = 10) was related to percent change in IGF-1 (r = .90; P < .001) and IGF-1 ratio (r = .75 P = .01). Individuals who went home (n = 7) had decreases in IGF-1 (-24 + 25%) and IGF-1 ratio (-36 + 50%), whereas individuals who went to inpatient facilities (n = 8) had increases in IGF-1 (37 + 46%) and IGF-1 ratio (30 + 40%). These differences were significant (IGF-1: P = .008; IGF-1 ratio: P = .01). CONCLUSION Our findings suggest that a decrease in IGF-1 and IGF-1 ratio during the first week of stroke is associated with favorable outcomes: shorter length of stay, greater independence at 1 month on the modified Rankin Scale, and discharging home.

Estimated Prestroke Peak VO2 Is Related to Circulating IGF-1 Levels During Acute Stroke

Background. Insulin-like growth factor-1 (IGF-1) is neuroprotective after stroke and is regulated by insulin-like binding protein-3 (IGFBP-3). In healthy individuals, exercise and improved aerobic fitness (peak oxygen uptake; peak VO2) increases IGF-1 in circulation. Understanding the relationship between estimated prestroke aerobic fitness and IGF-1 and IGFBP-3 after stroke may provide insight into the benefits of exercise and aerobic fitness on stroke recovery. Objective. The purpose of this study was to determine the relationship of IGF-1 and IGFBP-3 to estimated prestroke peak VO2 in individuals with acute stroke. We hypothesized that (1) estimated prestroke peak VO2 would be related to IGF-1 and IGFBP-3 and (2) individuals with higher than median IGF-1 levels will have higher estimated prestroke peak VO2 compared to those with lower than median levels. Methods. Fifteen individuals with acute stroke had blood sampled within 72 hours of hospital admission. Prestroke peak VO2 was estimated using a nonexercise prediction equation. IGF-1 and IGFBP-3 levels were quantified using enzyme-linked immunoassay. Results. Estimated prestroke peak VO2 was significantly related to circulating IGF-1 levels (r = .60; P = .02) but not IGFBP-3. Individuals with higher than median IGF-1 (117.9 ng/mL) had significantly better estimated aerobic fitness (32.4 ± 6.9 mL kg−1 min−1) than those with lower than median IGF-1 (20.7 ± 7.8 mL kg−1 min−1; P = .03). Conclusions. Improving aerobic fitness prior to stroke may be beneficial by increasing baseline IGF-1 levels. These results set the groundwork for future clinical trials to determine whether high IGF-1 and aerobic fitness are beneficial to stroke recovery by providing neuroprotection and improving function.

Decreased tidal volume may limit cardiopulmonary performance during exercise in subacute stroke.

PURPOSE: The aim of this retrospective study was to determine whether pulmonary function was reduced at submaximal and peak exercise in subacute stroke (SG) when compared with sedentary adults (CON). METHODS: Ten individuals with subacute stroke and 10 sedentary, age- and gender-matched adults performed cardiopulmonary exercise testing (CPET), using a recumbent stepper. We used independent t tests to determine between-group differences at peak effort. We used repeated-measures analysis of variance with Test Minute (minutes 1-6) as the within-subject factor and Group (SG, CON) as the between-subject factor to assess cardiopulmonary submaximal performance. RESULTS: The SG had significantly lower values (P < .05) for oxygen uptake, minute ventilation ( E), and tidal volume (VT) than CON at peak effort of the CPET. During CPET submaximal effort, we report a significant main effect for Test Minute and Group for VT and respiratory rate but no main effect of Group for E. To maintain adequate E during submaximal effort and decreased VT, higher respiratory rate was observed. CONCLUSIONS: These results suggest that diminished VT in subacute stroke patients may limit performance during submaximal and peak effort of CPET. Rehabilitation professionals should consider methods for improving pulmonary function during stroke rehabilitation.

Cardiopulmonary exercise testing is well tolerated in people with Alzheimer-related cognitive impairment.

OBJECTIVE To retrospectively assess whether cardiopulmonary exercise testing would be well tolerated in individuals with Alzheimer disease (AD) compared with a nondemented peer group. DESIGN We retrospectively reviewed 575 cardiopulmonary exercise tests (CPETs) in individuals with and without cognitive impairment caused by AD. SETTING University medical center. PARTICIPANTS Exercise tests (N=575) were reviewed for nondemented individuals (n=340) and those with AD-related cognitive impairment (n=235). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The main outcome measure for this study was reporting the reason for CPET termination. The hypothesis reported was formulated after data collection. RESULTS We found that in cognitively impaired individuals, CPETs were terminated because of fall risk more often, but that overall test termination was infrequent-5.5% versus 2.1% (P=.04) in peers without cognitive impairment. We recorded 6 cardiovascular and 7 fall risk events in those with AD, compared with 7 cardiovascular and 0 fall risk events in those without cognitive impairment. CONCLUSIONS Our findings support using CPETs to assess peak oxygen consumption in older adults with cognitive impairment caused by AD.

Recumbent Stepper Submaximal Test response is reliable in adults with and without stroke

Purpose The purpose of the present study was to determine the reliability of the exercise response (predicted peak VO2) using the total body recumbent stepper (TBRS) submaximal exercise test in: 1) healthy adults 20–70 years of age and 2) adults participating in inpatient stroke rehabilitation. We hypothesized that the predicted peak VO2 (Visit 1) would have an excellent relationship (r > 0.80) to predicted peak VO2 (Visit 2). We also wanted to test whether the exercise response at Visit 1 and Visit 2 would be significantly different. Methods Healthy adults were recruited from the Kansas City metro area. Stroke participants were recruited during their inpatient rehabilitation stay. Eligible participants completed 2 TBRS submaximal exercise tests between 24 hours and 5 days at similar times of day. Results A total of 70 participants completed the study. Healthy adults (n = 50) were 36 M, 38.1 ± 10.1 years and stroke participants (n = 20) were 15 M, 62.5 ± 11.8 years of age. The exercise response was reliable for healthy adults (r = 0.980, p<0.01) and stroke participants (r = 0.987, p<0.01) between Visit 1 and Visit 2. Repeated Measures ANOVA showed a significant difference in predicted values between the two visits for healthy adults (47.2 ± 8.4 vs 47.7 ± 8.5 mL∙kg-1∙min-1; p = 0.04) but not for stroke participants (25.0 ± 9.9 vs 25.3 ± 11.4 mL∙kg-1∙min-1; p = 0.65). Conclusion These results suggest that the exercise response is reliable using the TBRS submaximal exercise test in this cohort of healthy adults and stroke participants.