Dianne L. Marsden

A multidisciplinary group programme in rural settings for community-dwelling chronic stroke survivors and their carers: a pilot randomized controlled trial

Objectives: To explore whether a group programme for community-dwelling chronic stroke survivors and their carers is feasible in rural settings; to measure the impact of the programme on health-related quality of life and functional performance; and to determine if any benefits gained are maintained. Design: Randomized, assessor blind, cross-over, controlled trial. Setting: Rural outpatient. Subjects: Twenty-five community-dwelling, chronic stroke survivors and 17 carers of participant stroke survivors. Intervention: The intervention group undertook a once-a-week, seven-week group programme combining physical activity, education, self-management principles and a ‘healthy options’ morning tea. At completion, the control group crossed over to receive the intervention. Main measures: Stroke Impact Scale (stroke survivors), Health Impact Scale (carers), Six Minute Walk Test, Timed Up and Go, Caregiver Strain Index. Results: There were insufficient participants for results to reach statistical significance. However between-group trends favoured the intervention group in the majority of outcome measures for stroke survivors and carers. The majority of measures remained above baseline at 12 weeks post programme for stroke survivor participants. The programme was well attended. Of the seven sessions all participants attended four or more and 88% attended six or seven sessions. Conclusions: This novel programme incorporating physical activity, education and social interaction proved feasible to undertake by a stroke-specific multidisciplinary team in three rural Australian settings. This programme may improve and maintain health-related quality of life and physical functioning for chronic stroke survivors and their carers and warrants further investigation.

Characteristics of Exercise Training Interventions to Improve Cardiorespiratory Fitness After Stroke: A Systematic Review With Meta-analysis

Background. Cardiorespiratory fitness is low after stroke. Improving fitness has the potential to improve function and reduce secondary cardiovascular events. Objective. This review with meta-analysis aims to identify characteristics and determine the effectiveness of interventions to improve cardiorespiratory fitness after stroke. Methods. A systematic search and review with meta-analysis was undertaken. Key inclusion criteria were the following: peer-reviewed articles published in English, adult stroke survivors, an intervention with the potential to improve cardiorespiratory fitness, and peak oxygen consumption (VO2peak) assessed preintervention and postintervention via a progressive aerobic exercise test. Results. From 3209 citations identified, 28 studies were included, reporting results for 920 participants. Studies typically included chronic, ambulant participants with mild to moderate deficits; used an aerobic or mixed (with an aerobic component) intervention; and prescribed 3 sessions per week for 30 to 60 minutes per session at a given intensity. Baseline VO2peak values were low (8-23 mL/kg/min). Meta-analysis of the 12 randomized controlled trials demonstrated overall improvements in VO2peak of 2.27 (95% confidence interval = 1.58, 2.95) mL/kg/min postintervention. A similar 10% to 15% improvement occurred with both aerobic and mixed interventions and in shorter (≤3 months) and longer (>3 months) length programs. Only 1 study calculated total dose received and only 1 included long-term follow-up. Conclusions. The results demonstrate that interventions with an aerobic component can improve cardiorespiratory fitness poststroke. Further investigation is required to determine effectiveness in those with greater impairment and comorbidities, optimal timing and dose of intervention, whether improvements can be maintained in the longer term, and whether improved fitness results in better function and reduced risk of subsequent cardiovascular events.

Protocol variations and six-minute walk test performance in stroke survivors: a systematic review with meta-analysis.

Objective. To investigate the use of the six-minute walk test (6MWT) for stroke survivors, including adherence to 6MWT protocol guidelines and distances achieved. Methods. A systematic search was conducted from inception to March 2014. Included studies reported a baseline (intervention studies) or first instance (observational studies) measure for the 6MWT performed by stroke survivors regardless of time after stroke.  Results. Of 127 studies (participants n = 6,012) that met the inclusion criteria, 64 were also suitable for meta-analysis. Only 25 studies made reference to the American Thoracic Society (ATS) standards for the 6MWT, and 28 reported using the protocol standard 30 m walkway. Thirty-nine studies modified the protocol walkway, while 60 studies did not specify the walkway used. On average, stroke survivors walked 284 ± 107 m during the 6MWT, which is substantially less than healthy age-matched individuals. The meta-analysis identified that changes to the ATS protocol walkway are associated with reductions in walking distances achieved. Conclusion. The 6MWT is now widely used in stroke studies. The distances achieved by stroke patients indicate substantially compromised walking ability. Variations to the standard 30 m walkway for the 6MWT are common and caution should be used when comparing the values achieved from studies using different walkway lengths.

Trends in Stroke Attack Rates and Case Fatality in the Hunter Region, Australia 1996–2008

Background: The Hunter area in New South Wales, Australia, is a well-defined geographical area with a population of 578,486 (2006). This paper presents trends from 1996 to 2008 for prospectively registered hospital admissions of adults aged 20 years and above with acute stroke. Method: Crude, age-standardised and age-specific stroke attack rates per 100,000 population and case fatality rates at standard time points were calculated. A medical record audit of stroke and stroke mimics was undertaken to determine discharge coding accuracy. Results: 9,796 acute stroke events were registered among 8,830 individuals at 14 public acute hospitals. Crude and age-standardised attack rates decreased consistently from 1996 to 2008. Crude rates fell from 184 to 176 per 100,000 population and age-standardised rates from 129 to 106 per 100,000 (attack rate reduction of 0.85% per year, p = 0.027; and 2.38% per year, p < 0.001, respectively). Annual attack rates for females were on average 27.70% (p < 0.001) lower than for males. Age-specific rates fell for each age bracket between 45 and 74 years. Case fatality rates remained constant. There was a 97.5% proportion of agreement between audit and coding. Conclusion: This study demonstrates falling stroke attack rates but stable case fatality over 13 years in a mixed urban and rural population of New South Wales, Australia. It suggests benefits from cardio- and cerebrovascular prevention strategies; however, it also indicates that stroke remains a major disease burden in this region.

A Home- and Community-Based Physical Activity Program Can Improve the Cardiorespiratory Fitness and Walking Capacity of Stroke Survivors.

BACKGROUND The cardiorespiratory fitness of stroke survivors is low. Center-based exercise programs that include an aerobic component have been shown to improve poststroke cardiorespiratory fitness. This pilot study aims to determine the feasibility, safety, and preliminary efficacy of an individually tailored home- and community-based exercise program to improve cardiorespiratory fitness and walking capacity in stroke survivors. METHODS Independently ambulant, community-dwelling stroke survivors were recruited. The control (n = 10) and intervention (n = 10) groups both received usual care. In addition the intervention group undertook a 12-week, individually tailored, home- and community-based exercise program, including once-weekly telephone or e-mail support. Assessments were conducted at baseline and at 12 weeks. Feasibility was determined by retention and program participation, and safety by adverse events. Efficacy measures included change in cardiorespiratory fitness (peak oxygen consumption [VO2peak]) and distance walked during the Six-Minute Walk Test (6MWT). Analysis of covariance was used for data analysis. RESULTS All participants completed the study with no adverse events. All intervention participants reported undertaking their prescribed program. VO2peak improved more in the intervention group (1.17 ± .29 L/min to 1.35 ± .33 L/min) than the control group (1.24 ± .23 L/min to 1.24 ± .33 L/min, between-group difference = .18 L/min, 95% confidence interval [CI]: .01-.36). Distance walked improved more in the intervention group (427 ± 123 m to 494 ± 67m) compared to the control group (456 ± 101m to 470 ± 106m, between-group difference = 45 m, 95% CI: .3-90). CONCLUSIONS Our individually tailored approach with once-weekly telephone or e-mail support was feasible and effective in selected stroke survivors. The 16% greater improvement in VO2peak during the 6MWT achieved in the intervention versus control group is comparable to improvements attained in supervised, center-based programs.

Independently ambulant, community–dwelling stroke survivors have reduced cardiorespiratory fitness, mobility and knee strength compared to an age- and gender-matched cohort

Background: Most exercise interventions for stroke survivors are designed for those who have substantial motor and functional disabilities. There remains a group of well-recovered stroke survivors who have yet to be investigated in terms of their physical capacity and fitness levels. Objective: To assess and compare the physical capacities of independently ambulant, community-dwelling stroke survivors to age- and gender-matched comparison participants. Methods: Data were obtained from 17 stroke survivors participating in the How FITSS? Trial, all with functional ambulatory category of ≥4 and a self-selected walking speed ≥0.8 m s−1. An additional 17 healthy control participants were recruited. Cardiorespiratory fitness (CRF) was measured using oxygen consumption (VO2peak), and additional measures of walking speed (m s−1), leg strength and body composition were also assessed. Differences between groups were assessed by matched pairs t-tests. Effect sizes were calculated using Cohen’s d. Results: There were no significant differences in age, BMI, muscle mass or body fat between groups (p > 0.05). Peak VO2 was lower in the stroke group for the shuttle walk test (p = 0.037) and progressive cycle test (p = 0.019), as were all CRF test performance measures (p < 0.05). Stroke survivors walked significantly (p < 0.001) slower at both self-selected and fast speeds. Effect sizes of group differences for all leg strength variables were medium to large, with peak torque lower in the stroke group for all trials. Conclusions: Despite being independently ambulant and community dwelling, the CRF, walking speed and leg strength of this group were reduced compared to non-stroke comparison participants. These patients may benefit from undertaking targeted exercise programmes.

Cardiorespiratory fitness and walking endurance improvements after 12 months of an individualised home and community-based exercise programme for people after stroke

ABSTRACT Objective: To evaluate the immediate and longer-term effects of an individually tailored, home- and community-based exercise programme with ongoing remote support in people with stroke on cardiorespiratory fitness (CRF), ambulation and health-related quality of life (HRQoL). Methods: Twenty people 5.3 ± 3.5 months post stroke completed the 12-week HowFITSS? exercise programme aimed at increasing CRF and daily physical activity. Support was provided by phone and email, which decreased in frequency over time. Participants were assessed at baseline, then at 3, 6 and 12 months after initiation of the intervention. CRF (VO2peak) was evaluated using a portable metabolic system during the 6-minute walk test (6MWT), the Shuttle Walk Test (SWT) and the cycle graded exercise test (cGXT). Walking speed, balance, body composition, fatigue, depression and HRQoL were also measured. Results: CRF improved significantly from pre-intervention to 12-month follow-up on the 6MWT (Effect Size, ES = 0.87; p = 0.002) and cGXT (ES = 0.60; p < 0.001), with more modest improvements on the SWT (ES = 0.52; p = 0.251). From baseline to 12 months, significant within-participant improvements were found for self-selected walking speed, balance and HRQoL. Performances on the remaining tests were maintained over the post-intervention period. Conclusion: There may be health benefits of providing people with stroke an exercise intervention with long-term support that encourages increased regular physical activity.

Evaluation of three measures of cardiorespiratory fitness in independently ambulant stroke survivors

ABSTRACT Measuring cardiorespiratory fitness (CRF) in the stroke population is challenging. Currently, the recommended method is a graded exercise test (GXT) on an ergometer such as a treadmill or cycle, which may not always be possible. We investigated whether walking tests such as the six-minute walk test (6MWT) and the shuttle walk test (SWT) may be appropriate indicators of CRF in the stroke population. Twenty-three independently ambulant stroke survivors (11 men, age 61.5 ± 18.4 years) within one-year post stroke performed the 6MWT, SWT, and cycle GXT, during which peak oxygen consumption (VO2peak) and heart rate (HRpeak) were recorded. There were no differences (p > 0.05) in mean VO2peak among the three tests (min-max: 17.08–18.09 mL kg−1 min−1). For individuals, small discrepancies in VO2peak between the 6MWT and other tests were greater with higher fitness levels. HRpeak was significantly (p = 0.005) lower during the 6MWT. Correlations between VO2peak and performance measures within each test were high (6MWT VO2peak and distance: r = 0.78, SWT VO2peak and shuttles: r = 0.73, cycle GXT VO2peak and workload: r = 0.77) suggesting the performance measures may be clinically useful as proxy measures of CRF. Common comorbidities, such as lower-limb joint pain and poor balance, and participant’s fastest walking speed, should inform the choice of CRF test.