Janice J. Eng

Physical Activity and Exercise Recommendations for Stroke Survivors A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

Purpose— This scientific statement provides an overview of the evidence on physical activity and exercise recommendations for stroke survivors. Evidence suggests that stroke survivors experience physical deconditioning and lead sedentary lifestyles. Therefore, this updated scientific statement serves as an overall guide for practitioners to gain a better understanding of the benefits of physical activity and recommendations for prescribing exercise for stroke survivors across all stages of recovery. Methods— Members of the writing group were appointed by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and indicate gaps in current knowledge. Results— Physical inactivity after stroke is highly prevalent. The assessed body of evidence clearly supports the use of exercise training (both aerobic and strength training) for stroke survivors. Exercise training improves functional capacity, the ability to perform activities of daily living, and quality of life, and it reduces the risk for subsequent cardiovascular events. Physical activity goals and exercise prescription for stroke survivors need to be customized for the individual to maximize long-term adherence. Conclusions— The recommendation from this writing group is that physical activity and exercise prescription should be incorporated into the management of stroke survivors. The promotion of physical activity in stroke survivors should emphasize low- to moderate-intensity aerobic activity, muscle-strengthening activity, reduction of sedentary behavior, and risk management for secondary prevention of stroke.

Resistance and agility training reduce fall risk in women aged 75 to 85 with low bone mass: a 6-month randomized, controlled trial.

Objectives: To compare the effectiveness of group resistance and agility‐training programs in reducing fall risk in community‐dwelling older women with low bone mass.

A Community-Based Fitness and Mobility Exercise Program for Older Adults with Chronic Stroke: A Randomized, Controlled Trial

Objectives: To examine the effects of a community‐based group exercise program for older individuals with chronic stroke.

How Active Are People With Stroke? Use of Accelerometers to Assess Physical Activity

Background and Purpose— Accelerometers are a unique tool used to objectively measure free-living physical activity, but their reliability for people with stroke has not been established. The primary aim was to assess the day-to-day reliability of these instruments for the paretic and nonparetic hips. The secondary aims were to measure the amount of physical activity with accelerometers that people with stroke undertake in the community and its relationship with walking capacity (6-minute walk test distance). Methods— Forty people with stroke wore one Actical accelerometer on each hip for 3 consecutive days at home and during the 6-minute walk test in the laboratory. The accelerometer measured physical activity using total activity counts per day and energy expenditure (kcal/d). Results— Excellent intraclass correlation coefficients (ICCs) for the activity counts (paretic hip ICC[1,3]=0.95, nonparetic hip ICC[1,3]=0.94) and for the energy expenditure (paretic hip ICC[1,3]=0.95, nonparetic hip ICC[1,3]=0.95) were found across the 3 consecutive days at home. Excellent ICCs were also found between the paretic versus the nonparetic hips for the activity counts (ICC[1,3]=0.98) and for the energy expenditure (ICC[1,3]=0.96). Free-living physical activity was very low and 58% of the participants did not meet recommended physical activity levels. Only moderate correlations (r=0.6 to 0.73, P<0.001) were found between the 6-minute walk test distance in the laboratory and 3-day physical activity recording at home. Conclusions— The accelerometer was found to be a reliable objective instrument. The use of accelerometers quantified the low level of free-living physical activity of people with stroke.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

Purpose— The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. Methods— Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council’s Scientific Statement Oversight Committee and the AHA’s Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. Results— Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential. Conclusions— As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.)

Submaximal exercise in persons with stroke: Test-retest reliability and concurrent validity with maximal oxygen consumption

OBJECTIVE To establish the test-retest reliability and concurrent validity with maximum oxygen consumption (VO2max) for 3 submaximal exercise tests in persons with chronic stroke: (1) submaximal treadmill test, (2) submaximal cycle ergometer test, and (3) 6-minute walk test (6MWT). DESIGN Prospective study using a convenience sample. SETTING Free-standing tertiary rehabilitation center. PARTICIPANTS A volunteer sample of 12 community-dwelling individuals who had a stroke with moderate motor deficits. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Heart rate, blood pressure, and oxygen consumption (VO2) were assessed during the exercise tests. RESULTS Test-retest reliability was good to excellent for the exercise tests (maximal and submaximal tests). VO2 for all submaximal measures related to VO2max (r range, .66-.80). Neither the 6MWT distance, self-selected gait speed, nor hemodynamic measures related to VO2max. CONCLUSION The VO2 measures of the submaximal exercise tests had excellent reliability and good concurrent validity with VO2max. Submaximal exercise tests may be a method by which to monitor the effects of interventions after a screening test (eg, symptom-limited graded exercise test, dobutamine stress echocardiograph).

Symmetry in vertical ground reaction force is accompanied by symmetry in temporal but not distance variables of gait in persons with stroke

The purpose of this study was to (1) determine whether symmetry in temporal-distance (T-D) measures is accompanied by symmetry in kinetic measures during self-paced gait and (2) evaluate the effect of symmetry on gait speed in individuals with chronic stroke. A symmetry index was calculated for stance time, swing time, step length and vertical ground reaction force (GRF) for 28 individuals with stroke (age: 62.5+/-8.2 years). Spearman correlation revealed that (a) gait speed was correlated with the symmetry of temporal measures and GRF and (b) symmetry in GRF was correlated with symmetry in temporal but not distance measures of gait (P<0.05). The results provide support for promoting temporal and kinetic symmetry in the gait of persons with stroke.

The use of aerobic exercise training in improving aerobic capacity in individuals with stroke: a meta-analysis

Objective: To determine whether aerobic exercise improves aerobic capacity in individuals with stroke. Design: A systematic review of randomized controlled trials. Databases searched: MEDLINE, CINAHL, EMBASE, Cochrane Database of Systematic Reviews and Physiotherapy Evidence Database were searched. Inclusion criteria: Design: randomized controlled trials (RCTs). Participants: individuals with stroke. Interventions: aerobic exercise training aimed at improving aerobic capacity. Outcomes: Primary outcomes: aerobic capacity (peak oxygen consumption (VO2), peak workload). Secondary outcomes: walking velocity, walking endurance. Data analysis: The methodological quality was assessed by the PEDro scale. Meta-analyses were performed for all primary and secondary outcomes. Results: Nine articles (seven RCTs) were identified. The exercise intensity ranged from 50% to 80% heart rate reserve. Exercise duration was 20–40 min for 3–5 days a week. The total number of subjects included in the studies was 480. All studies reported positive effects on aerobic capacity, regardless of the stage of stroke recovery. Meta-analysis revealed a significant homogeneous standardized effect size (SES) in favour of aerobic exercise to improve peak VO2 (SES 0.42; 95% confidence interval (CI) 0.15–0.69; P=0.001) and peak workload (SES 0.50; 95% CI 0.26–0.73; P<0.001). There was also a significant homogeneous SES in favour of aerobic training to improve walking velocity (SES 0.26; 95% CI 0.05–0.48; P=0.008) and walking endurance (SES 0.30; 95% CI 0.06–0.55; P=0.008). Conclusions: There is good evidence that aerobic exercise is beneficial for improving aerobic capacity in people with mild and moderate stroke. Aerobic exercise should be an important component of stroke rehabilitation.

A Systematic Review of the Management of Autonomic Dysreflexia After Spinal Cord Injury

OBJECTIVE To review systematically the clinical evidence on strategies to prevent and manage autonomic dysreflexia (AD). DATA SOURCES A key word search of several databases (Medline, CINAHL, EMBASE, and PsycINFO), in addition to manual searches of retrieved articles, was undertaken to identify all English-language literature evaluating the efficacy of interventions for AD. STUDY SELECTION Studies selected for review included randomized controlled trials (RCTs), prospective cohort studies, and cross-sectional studies. Treatments reviewed included pharmacologic and nonpharmacologic interventions for the management of AD in subjects with spinal cord injury. Studies that failed to assess AD outcomes (eg, blood pressure) or symptoms (eg, headaches, sweating) were excluded. DATA EXTRACTION Studies were critically reviewed and assessed for their methodologic quality by 2 independent reviewers. DATA SYNTHESIS Thirty-one studies were assessed, including 6 RCTs. Preventative strategies to reduce the episodes of AD caused by common triggers (eg, urogenital system, surgery) primarily were supported by level 4 (pre-post studies) and level 5 (observational studies) evidence. The initial acute nonpharmacologic management of an episode of AD (ie, positioning the patient upright, loosening tight clothing, eliminating any precipitating stimulus) is supported by clinical consensus and physiologic data (level 5 evidence). The use of antihypertensive drugs in the presence of sustained elevated blood pressure is supported by level 1 (prazosin) and level 2 evidence (nifedipine and prostaglandin E(2)). CONCLUSIONS A variety of options are available to prevent AD (eg, surgical, pharmacologic) and manage the acute episode (elimination of triggers, pharmacologic); however, these options are predominantly supported by evidence from noncontrolled trials, and more rigorous trials are required.

Exercise leads to faster postural reflexes, improved balance and mobility, and fewer falls in older persons with chronic stroke.

Objectives: To determine the effect of two different community‐based group exercise programs on functional balance, mobility, postural reflexes, and falls in older adults with chronic stroke.