Marilyn MacKay-Lyons

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.

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.)

Exercise capacity early after stroke

MacKay-Lyons MJ, Makrides L. Exercise capacity early after stroke. Arch Phys Med Rehabil 2002;83:1697-702. Objective: To evaluate exercise capacity of patients with a poststroke interval of less than 1 month. Design: Prospective, cohort, observational study. Setting: Exercise testing laboratory in a tertiary care hospital. Participants: Twenty-nine patients (mean age ± standard deviation, 64.9±13.5y) with a poststroke interval of 26.0±8.8 days. Interventions: Not applicable. Main Outcome Measure: Peak exercise capacity (VO2peak) was measured by open-circuit spirometry during maximal effort treadmill walking with 15% body-weight support. Results: Mean VO2peak was 14.4±5.1mL · kg−1 · min−1 or 60%±16% of age- and sex-related normative values for sedentary healthy adults. Conclusions: Exercise capacity approximately 1 month after stroke was compromised. Further research is needed to elucidate the physiologic basis of this low capacity.

ArticlesExercise capacity early after stroke☆1☆2☆3☆4☆5☆6☆7☆8☆9☆10

MacKay-Lyons MJ, Makrides L. Exercise capacity early after stroke. Arch Phys Med Rehabil 2002;83:1697-702. Objective: To evaluate exercise capacity of patients with a poststroke interval of less than 1 month. Design: Prospective, cohort, observational study. Setting: Exercise testing laboratory in a tertiary care hospital. Participants: Twenty-nine patients (mean age ± standard deviation, 64.9±13.5y) with a poststroke interval of 26.0±8.8 days. Interventions: Not applicable. Main Outcome Measure: Peak exercise capacity (VO2peak) was measured by open-circuit spirometry during maximal effort treadmill walking with 15% body-weight support. Results: Mean VO2peak was 14.4±5.1mL · kg−1 · min−1 or 60%±16% of age- and sex-related normative values for sedentary healthy adults. Conclusions: Exercise capacity approximately 1 month after stroke was compromised. Further research is needed to elucidate the physiologic basis of this low capacity.

Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015:

Stroke rehabilitation is a progressive, dynamic, goal-orientated process aimed at enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative, social and/or functional activity level. After a stroke, patients often continue to require rehabilitation for persistent deficits related to spasticity, upper and lower extremity dysfunction, shoulder and central pain, mobility/gait, dysphagia, vision, and communication. Each year in Canada 62,000 people experience a stroke. Among stroke survivors, over 6500 individuals access in-patient stroke rehabilitation and stay a median of 30 days (inter-quartile range 19 to 45 days). The 2015 update of the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines is a comprehensive summary of current evidence-based recommendations for all members of multidisciplinary teams working in a range of settings, who provide care to patients following stroke. These recommendations have been developed to address both the organization of stroke rehabilitation within a system of care (i.e., Initial Rehabilitation Assessment; Stroke Rehabilitation Units; Stroke Rehabilitation Teams; Delivery; Outpatient and Community-Based Rehabilitation), and specific interventions and management in stroke recovery and direct clinical care (i.e., Upper Extremity Dysfunction; Lower Extremity Dysfunction; Dysphagia and Malnutrition; Visual-Perceptual Deficits; Central Pain; Communication; Life Roles). In addition, stroke happens at any age, and therefore a new section has been added to the 2015 update to highlight components of stroke rehabilitation for children who have experienced a stroke, either prenatally, as a newborn, or during childhood. All recommendations have been assigned a level of evidence which reflects the strength and quality of current research evidence available to support the recommendation. The updated Rehabilitation Clinical Practice Guidelines feature several additions that reflect new research areas and stronger evidence for already existing recommendations. It is anticipated that these guidelines will provide direction and standardization for patients, families/caregiver(s), and clinicians within Canada and internationally.

Reduced Cardiorespiratory Fitness after Stroke: Biological Consequences and Exercise-Induced Adaptations

Evidence from several studies consistently shows decline in cardiorespiratory (CR) fitness and physical function after disabling stroke. The broader implications of such a decline to general health may be partially understood through negative poststroke physiologic adaptations such as unilateral muscle fiber type shifts, impaired hemodynamic function, and decrements in systemic metabolic status. These physiologic changes also interrelate with reductions in activities of daily living (ADLs), community ambulation, and exercise tolerance, causing a perpetual cycle of worsening disability and deteriorating health. Fortunately, initial evidence suggests that stroke participants retain the capacity to adapt physiologically to an exercise training stimulus. However, despite this evidence, exercise as a therapeutic intervention continues to be clinically underutilized in the general stroke population. Far more research is needed to fully comprehend the consequences of and remedies for CR fitness impairments after stroke. The purpose of this brief review is to describe some of what is currently known about the physiological consequences of CR fitness decline after stroke. Additionally, there is an overview of the evidence supporting exercise interventions for improving CR fitness, and associated aspects of general health in this population.

Dual effects of body-weight supported treadmill training on cardiovascular fitness and walking ability early after stroke: a randomized controlled trial.

Background. Body-weight-supported treadmill training (BWSTT) to train both fitness and ambulation has not been investigated. Objective. To compare the effectiveness of BWSTT to dose-equivalent usual care (UC) in improving cardiovascular fitness and walking early after stroke. Methods. Participants were randomly assigned to 1 of 2 interventions: BWSTT + UC or UC. All individuals participated in 60-minute physiotherapy sessions 5 times weekly as inpatients for 6 weeks and 3 times weekly as outpatients for another 6 weeks. Baseline, posttraining, 6-, and 12-month follow-up outcome measures were as follows: primary, fitness (peak oxygen consumption, VO2peak) and walking ability (6-Minute Walk Test [6MWT] and 10-m walk); secondary, Berg Balance Scale (BBS) and motor impairment (Chedoke-McMaster Stages of Recovery [CMSR] Leg and Foot). Results. In all, 50 individuals (mean age, 60 ± 14 years; mean event-to-randomization, 23 ± 5 days; 29 men) participated. No adverse events occurred. BWSTT improved VO2peak by 30%, which was significantly greater than the 8% improvement observed for UC (P = .004 between groups). Similarly, there were significant Time × Group interactions for 6MWT and CMSR Foot, with BWSTT outperforming UC for gains in distance (P = .15; 48% vs 19%, respectively) and stage (P = .01; 1.0 vs 0.3, respectively). No group effect was seen for 10-m walk speed, BBS, or CMSR Leg, with both groups demonstrating significant gains. In general, gains observed were preserved for 12 months. Conclusions. BWSTT elicits greater improvements in cardiovascular fitness and walking endurance than UC in the subacute poststroke period. These gains are largely sustained for 1 year.

A randomized trial of two home-based exercise programmes to improve functional walking post-stroke

Objective: To estimate the relative effectiveness in improving walking ability and other mobility and health outcomes post-stroke of two home-based exercise programmes – stationary cycling and an exercise and walking programme. Design: An observer-blinded, randomized, pragmatic, trial with repeated measures. Setting: Hospital centers in two Canadian cities. Subjects: People within 12 months of acute stroke who were able to walk >10 meters independently and healthy enough to engage in exercise. Interventions: Two dose-equivalent interventions, one involving stationary cycling and the other disability-targeted interventions were tested. Both protocols required daily moderate intensity exercise at home building up to 30 minutes per day. One group exercised on a stationary bicycle, the second group carried out mobility exercises and brisk walking. Main measures: The primary outcome was walking capacity as measured by the six-minute walk test (6MWT). Secondary outcomes were physical function, role participation, health-related quality of life exercise adherence, and adverse events. Results: The study failed to meet recruitment targets: 87 participants (cycle group, n = 43; exercise group, n = 44) participated. No significant effects of group or time were revealed for the 6MWT, which was approximately 320 m at randomization. A significant effect for role participation was found in favor of the exercise group (global odds ratio (OR) for cycling vs. exercise was 0.51; 95% confidence interval (CI), 0.27–0.95). Change in the 6MWT between highest and lowest adherence categories was statistically significant (p = 0.022). Conclusions: Both programmes were equally effective in maintaining walking capacity after discharge from stroke rehabilitation; or were equally ineffective in improving walking capacity. Clinical Trials Gov number: NCT00786045.

Utilization of aerobic exercise in adult neurological rehabilitation by physical therapists in Canada

Background and Purpose: Although aerobic exercise (AE) has been shown to improve aerobic capacity and reduce morbidity in neurological populations, its application is challenging. The purpose of this study was to survey Canadian physical therapists practicing in adult neurorehabilitation regarding the use of AE in clinical practice. Methods: Members of the Neurosciences Division of the Canadian Physiotherapy Association were invited to participate in a Web-based survey. Results: Response rate was 36% (N = 155) with every Canadian province represented. The majority of respondents were females in full-time practice for more than 15 years. The majority (88%) agreed/strongly agreed with the following: “AE should be incorporated into treatment programs of patients with neurological conditions.” Although 77% prescribed AE, barriers to use included patient concerns (cardiac status, cognitive/perceptual deficits, fatigue) and operations (lack of staff, time, screening tools). The most commonly used screening tools were health records and patient responses to exercise and the least common was exercise stress tests. Overground walking and cycle ergometry were the most frequently used AE modes, and general response to exercise and patient feedback were most frequently used for determining exercise intensity and monitoring AE. Discussion and Conclusions: Respondents clearly recognized the importance of AE in neurorehabilitation. Barriers to application of AE and limitations in the use of appropriate screening and training procedures need to be addressed to advance clinical utilization of AE in neurological practice. Understanding current patterns of utilization of AE is important for the development of professional education initiatives and clinical guidelines for best practices in AE for neurological populations. Video Abstract available (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A40) for more insights from the authors.

Getting on with the rest of your life following stroke: a randomized trial of a complex intervention aimed at enhancing life participation post stroke

Objective: To enhance participation post stroke through a structured, community-based program. Design: A controlled trial with random allocation to immediate or four-month delayed entry. Setting: Eleven community sites in seven Canadian cities. Subjects: Community dwelling persons within five years of stroke onset, cognitively intact, able to toilet independently. Interventions: Evidence-based program delivered in three 12-week sessions including exercise and project-based activities, done as individuals and in groups. Main measures: Hours spent per week in meaningful activities outside of the home and Reintegration to Normal Living Index; Stroke-Specific Geriatric Depression Scale, Apathy Scale, gait speed, EuroQuol EQ-5D, and Preference-Based Stroke Index. All measures were transformed to a scale from 0 to 100. Assessments prior to randomization, after the first session at three months, six months, 12 months, and 15 months. Results: A total of 186 persons were randomized. The between-group analysis showed no disadvantage to waiting and so groups were combined and a within-person analysis was carried out at three time points. There were statistically significant increases in all study outcomes on average over all persons. Over 45% of people met or exceeded the pre-specified target of a three hour per week increase in meaningful activity and this most often took a full year of intervention to achieve. Greatest gains were in satisfaction with community integration (mean 4.78; 95% CI: 2.01 to 7.55) and stroke-specific health-related quality of life (mean 4.14; 95% CI: 2.31 to 5.97). Conclusions: Community-based programs targeting participation are feasible and effective, but stroke survivors require time to achieve meaningful gains.