Stroke -1

Exercise Tolerance and Exercise Prescription (ExRx) for Stroke Clients

Stroke Background

  • Stroke Definition: A medical condition characterized by the sudden loss of blood supply to a part of the brain, leading to a deterioration in brain function. It can result in various physical and cognitive impairments.

  • Typical Effects of Stroke:
      - Loss of motor control affecting arms and legs, typically unilateral (one side of the body).
      - Loss of sensory feedback from limbs, impacting coordination and movement.
      - Autonomic dysfunction and disordered reflexes, contributing to other complications and impaired responses to exercise.

Response to Exercise

  • Stroke significantly alters the body's normal exercise response due to neurological deficits:
      - Extent of Damage: The nature of the neurological deficits including weakness and paralysis in lower limbs, impaired trunk balance, and disruption to upper limb motor functions impact exercise capabilities.
      - Cognitive Impairment: Communication problems may hinder a person's ability to follow instructions which is necessary for effective exercise programming.
      - Co-Morbid Conditions: Other issues such as cardiovascular and orthopedic problems may exacerbate exercise-related complications.

Exercise Testing

  • Due to the potential for co-morbid coronary artery disease (CAD), stroke patients should be assessed by a healthcare practitioner and may require clinical stress testing prior to commencing exercise:
      - Exercise Precautions: High blood pressure, increased risk of falls, potential cardiac arrhythmias, and medication interactions must be considered.

Special Treadmill Protocol for Low-Intensity Exercise Testing

  • Initial Workload: 0.22 m/s (0.8 km/h) at 0% grade for 1 minute.

  • Increments: Increase by 0.45 m/s (1.6 km/h) each minute.

  • Monitoring: ECG and Blood Pressure readings, patient subjective tolerance, and gait stability are all critical measurements.

Special Cycle Protocol for Low-Intensity Exercise Testing

  • Equipment: Motorized isokinetic cycle ergometer.

  • Initial Workload: 5-10 W for 1-2 minutes.

  • Increments: Increase by 5-15 W each minute.

  • Monitoring: ECG and Blood Pressure readings, patient subjective tolerance, and signs/symptoms.

  • End Goal: Exercise duration of 6 to 12 minutes, progressing to volitional fatigue or signs of cardiopulmonary distress.

Exercise Prescription

  • Fundamental Components of Exercise Prescription for Chronic Stroke Survivors:
      - Aerobic Fitness (4 - more common for younger)
      - Muscle Strength and Endurance (1)
      - Functional Training and Motor Control for Activities of Daily Living (ADLs) (3)
      - Hemiparetic Balance Training (2)
      - Stroke-specific Flexibility
      - Other relevant components such as assistive devices and ataxia training.

Basic Exercise Prescription Components for Chronic Stroke

  • Modality Considerations: A comprehensive ‘whole body’ exercise approach, taking into consideration the patient’s age and functional impairments.
      - Resistance Training:
        - Focuses on strength, power, and muscle endurance while being cautious of blood pressure changes.
      - Aerobic Training:
        - Should align with what the patient can safely and comfortably do, incorporating any muscle that is predominantly slow-twitch to aid metabolic function (blood glucose, lipids).
      - Balance and Flexibility Training:
        - Aimed at restoring both sitting and standing balance, while minimizing shortening and contracture in spastic muscles.

Exercise Outcomes and Evidence

  • Cochrane Review Findings on Cardiorespiratory Training: Significant improvements were observed in cardiovascular fitness (VO2peak) among stroke patients engaging in exercise regimes.

  • LIDCOMBE Chronic Stroke Study (2001-2010): Evaluated the effects of Progressive Resistance Training (PRT) and aerobic exercise on stroke recovery, noting improvement in VO2peak without corresponding changes in walking ability.

  • Example of Exercise Protocol:
      - Task-Specific Strength Training: Utilize box-stepping with lifting body mass of 5-35 cm beneficial for home training.
      - Non-Task Specific Strength Training: Air-pressure strength machines focusing on local muscle strength.

  • 1-RM Training Guidelines: Include sets, reps, and predicted one-repetition maximum (1-RM) to target muscle strength, power, and endurance with respect to functional outcomes.

Key Implications and Takeaways

  • Training Benefits: Exercise training can improve function at submaximal work tasks, enhancing both aerobic fitness and strength, which in turn improves community ambulation. However, task-specific training remains essential for better functional outcomes.

  • Technology Use in Rehabilitation: The integration of assistive technology such as Functional Electrical Stimulation (FES) devices can enhance exercise potential, utilizing systems like the Odstock Dropped Foot Stimulator to address gait limitations associated with foot drop syndrome.

Conclusion

  • Longitudinal Findings: Cardiorespiratory fitness often remains impaired soon after a stroke and does not show significant improvement over time without intervention.

  • Exercise Programs Recommendations: Stroke patients are capable of participating in structured fitness programs that combine resistance training, functional balance, and aerobic components, leading to augmented cardiovascular fitness and overall quality of life improvements.

  • Role of Exercise Specialists: There exists a specialized niche for exercise rehabilitation professionals in enhancing the effectiveness of exercise programs combined with technology for stroke patients.