Physical Fitness Training After Stroke

Can an exercise program help this patient?

“Mr Chan” is a 72-year-old man who sustained a left middle cerebral artery territory infarct 6 weeks previously. He completed inpatient stroke rehabilitation and is starting outpatient services. Mr Chan sustained a mild myocardial infarction 3 years previously. Prior to his stroke, he smoked for 23 years but has not smoked since. He is retired.

Mr Chan's resting heart rate (HR) is 68 bpm, and his blood pressure is 128/69 mm Hg. He is currently taking medications to manage his blood pressure (ramipril 5 mg, amlodipine 5 mg), type 2 diabetes (metformin 500 mg twice a day, Avandia [GlaxoSmithKline, Research Triangle Park, North Carolina] 2 mg twice a day), and depressive symptoms (fluoxetine 20 mg). He also is taking a blood thinner (Plavix [Bristol-Myers Squibb, Princeton, New Jersey] 75 mg). He is obese (weight=107 kg [235 lb], body mass index=30.9 kg/m²).

On examination, the physical therapist noted that Mr Chan exhibited residual right-sided weakness. The patient ambulates independently indoors and outdoors with a single-point cane but without splints or orthoses. He has experienced 1 noninjurious fall since being discharged home. His self-selected gait speed was 0.85 m/s, and his Six-Minute Walk Test (6MWT) distance was 301 m. Although these values are higher than baseline values of the studies included in the review (average self-selected gait speed=0.54 m/s, 6MWT distance=215.9 m), they are nonetheless compromised, representing 64%¹⁹ and 55%²⁰ of age-matched values, respectively. His Berg Balance Scale score was 50/56 (higher scores indicate better balance).

How did the physical therapist apply the results of this Cochrane review to Mr Chan?

The physical therapist considered the findings of the Cochrane review² to decide whether Mr Chan was a suitable candidate for physical fitness training. Using the PICO (Patient, Intervention, Comparison, Outcome) format, the therapist asked the question: In a 72-year-old man who is 6 weeks poststroke, will a supervised exercise program be beneficial to improve aerobic fitness and walking ability? The therapist determined that the systematic review by Brazzelli and colleagues² provided relevant information that allowed him to answer this question. Although the mean age of the participants in the reviewed studies was younger (64 years) than Mr Chan's age, the mean time since stroke onset falls within the range of trials included in the review (8.8 days to 7.7 years after stroke onset), and the majority of studies involved participants with similar presentation (mild to moderate stroke, capable of ambulation). Although Mr Chan's gait speed and ambulatory capacity were higher than studies included in the review, his walking was still compromised relative to that of age-matched individuals who are healthy. The physical therapist also understood that his patient is at risk for recurrent cardiovascular events given his medical history (previous myocardial infarction and current stroke) and presence of cardiovascular risk factors (high blood pressure and type 2 diabetes).

An exercise test confirmed that Mr Chan was safe to proceed with exercise training. Peak oxygen consumption (V̇o₂peak) was 16.2 mL·kg⁻¹·min⁻¹, representing 55% of age-matched values.⁷ Based on his assessment of the evidence from the systematic review and using findings from his own physical therapy assessment and the exercise test results, the physical therapist determined an FITT (frequency, intensity, time, and type) prescription for Mr Chan (Tab. 2).

The physical therapist ensured that Mr Chan was provided with specific instructions and education on how to exercise safely on his own during the at-home sessions, including the target HR range, and how to monitor intensity using 10-second pulse rate and the rating of perceived exertion scale. In view of his diabetes, Mr Chan also was advised to monitor his pre-exercise and postexercise glucose levels, and was given advice about recognizing and managing signs of hypoglycemia.

How well do the outcomes of the intervention provided to Mr Chan match those suggested by the systematic review?

Mr Chan completed 83% of all possible exercise sessions, which is aligned with attendance rates reported in the Cochrane review.²

After 12 weeks of training, Mr Chan demonstrated improvement in 6MWT distance from 301 to 370 m (72% of age-matched values²⁰). This improvement aligns with the conclusions from the Cochrane review, and the increase is greater than the 51-m change considered to reflect real (clinical) improvement for individuals with stroke.²¹ Posttraining gait speed remained unchanged from baseline (0.85 m/s). Although the systematic review reported a significant mean difference (MD) in preferred gait speed between cardiorespiratory training and the control intervention, the absolute change was relatively small (MD=4.68 m/min, or 0.078 m/s) and not dissimilar to Mr Chan's results. This MD also is less than the values of 0.16²² to 0.175²³ m/s previously reported for a clinically important difference in people with stroke. Mr Chan's Berg Balance Scale score increased by 1 point (to 51/56), which aligns with the nonsignificant difference found in the Cochrane review (MD between cardiorespiratory training and control intervention=1.52 points). Resting HR and blood pressure were unchanged after training. Body composition measures also did not change after exercise training, which is aligned with evidence suggesting that exercise combined with diet interventions is most effective in weight loss.²⁴

Overall, Mr Chan's immediate posttraining outcomes were aligned with those of the systematic review.² Mr Chan also demonstrated improvements in resting HR, but these outcomes were not included in the Cochrane review.

This review also showed that most functional improvements observed immediately after fitness training were not maintained at follow-up,² underscoring the importance of sustained exercise programming. As such, when planning for discharge from outpatient services, the physical therapist ensured that Mr Chan was advised on how to safely continue, monitor, and progress his exercise program. They also discussed ongoing exercise options, and Mr Chan opted to supplement his at-home program with a twice-weekly seniors exercise program provided at a local community center. Such programs may provide transitional support after discharge and supervision to help ensure that exercise training continues, and they offer socialization and peer support that can facilitate long-term adherence.

Can you apply the results of this systematic review to your own patients?

The findings from this Cochrane review support the implementation of fitness training after stroke. The studies included in this review establish the feasibility of fitness training in a variety of settings, regardless of whether it is implemented during or after hospital care. The majority of studies involved individuals in the later stages (more than 1 month) poststroke. There is clear evidence to support the use of cardiorespiratory training to improve walking parameters (speed and endurance), especially when walking is incorporated into the training program.

There is also some evidence that cardiorespiratory or mixed (ie, combined cardiorespiratory and resistance) training improves aerobic capacity after stroke. Because higher levels of fitness are known to be associated with lower risk for cardiovascular morbidity and mortality,^8–11 additional potential benefits to cardiovascular health may be gained from fitness training after stroke.

Although there has been substantial growth in scientific evidence regarding poststroke exercise in recent years, ongoing research is needed. The majority of research in this area has focused on the chronic stages of stroke, but there is evidence supporting the implementation of early aerobic training poststroke.²⁵ Future research in this field may refine exercise prescription to optimize benefit across individuals with a broader range of clinical presentations (eg, age groups, stroke types, comorbidities, symptom severity).

What can be advised based on the results of this systematic review?

Benefits to walking and cardiorespiratory fitness may be derived from cardiorespiratory training after stroke. Task specificity also appears to be important, as cardiorespiratory or mixed training can improve cardiorespiratory fitness, and when training included walking activity as a training modality, improvements in walking speed and endurance can be demonstrated.

To promote retention of benefits gained from exercise, physical therapists should be familiar with local community programs that provide their clients with ongoing opportunities to exercise and promote healthy behaviors through active lifestyles. Without continued stimulus, this review showed that most functional improvements observed immediately after fitness training were not retained at follow-up. Interestingly, improvements in walking parameters were retained even after the program had ended, which may result from increased levels of habitual physical activity (including walking) adopted by the study participants.