1. R.C. Sullivan & S.N. Meadows Waist Circumference (cm)
The Effects of Group Based Exercise Rehabilitation in Stroke Survivors - Update School of Sport and Exercise Sciences, University of Kent, The Medway Building, Chatham Maritime, Kent. ME4 4AG
R.C. Sullivan & S.N. Meadows
Introduction
Stroke is the second leading cause of death (WHO, 2015) & disability adjusted life years worldwide (Murray, et al., 2012). Following a stroke, it is important to manage modifiable risk factors. Hypertension contributes to around half of strokes in the UK. Exercise training post-stroke has been shown to significantly reduce blood pressure (Faulkner, et al., 2013). Physical inactivity also increases the incidence of stroke. Activity levels often decline post-stroke due to loss of movement, mobility & reduced functional capacity (Saunders, et al., 2016). The benefits of exercise training in stroke rehabilitation can improve a wide range of factors including quality of life & secondary stroke incidence (Saunders, Grieg & Mead 2014).
Table 1. Results of health & functional assessments (mean ± SD) at baseline & post-12 week exercise programme. Resting SBP, DBP, 6MWD (m), peak HR (bpm), TUG mean (secs) & GS left (mean) showed marked improvements.
Mean age of participants = 60.9 (±11.8) years.
Assessment
Pre (n=17)
(mean ±SD)
Post (n=17)
Difference
P value
Weight (kg)
84.47 (±11.65)
85.15 (±12.32)
0.68
0.33
BMI (kg.m2)
29.35 (±4.44)
29.71 (±4.99)
0.36
0.22
Waist Circumference (cm)
97 (±10.40)
97.16 (±10.07)
0.16
0.82
Resting HR (bpm)
70.65 (±12.84)
73 (±13.16)
2.35
0.21
Resting SBP (mmHg)
(±16.75)
135 (±14.41)
-13.18
0.001
Resting DBP (mmHg)
83.06 (±13.12)
77.82 (±10.22)
-5.24
0.02
6MWD (m)
(±110.50)
(±119.92)
77.41
6MWD Peak HR (bpm)
94.60 (±17.21)
102 (20.27)
7.40
0.01
6MWD Peak RPE (Borg 6-20)
11.53 (±3.18)
11.18 (2.79)
-0.35
0.65
TUG mean (secs)
12.77 (±7.38)
11.02 (±5.65)
-1.75
TUG RPE (Borg 6-20)
8.94 (±2.61)
8.86 (±2.10)
-0.08
GS Left (mean)
24.62 (±15.37)
27.72 (±14.76)
3.1
0.04
GS Right (mean)
26.06 (±12.09)
28.26 (±9.27)
2.2
0.14
Study Aims and Hypothesis
Aims: To provide a weekly group exercise session for stroke survivors in a local community setting using cardiovascular and strength exercises. To investigate the benefits of exercise in stroke rehabilitation.
Hypothesis: Following a 12 week exercise programme functional ability will improve, along with key health parameters, e.g. reductions in SBP.
Methods
Recruitment
Individuals were either referred by the local stroke services or their GP. Promoting the exercise class at stroke support groups also had a positive impact on attendance. Universal referral criteria does not exist so a referral form was designed to facilitate patient screening & risk stratification.
Assessments
Health & functional assessments were completed before attendance & repeated following an average of 12 exercise sessions.
Health assessments: Resting heart rate (RHR), blood pressure (BP), height, weight, BMI, waist circumference.
Functional Assessments: Six-minute walk distance (6MWD), timed up & go (TUG) & bilateral grip strength (GS).
Exercise Intervention
Warm Up
Graded 15 minute cardiovascular warm-up, consisting of various multi-directional mobility movements, co-ordination & stretching exercises.
Cardiovascular (CV) Conditioning Component
Circuit format of 10 exercise stations. Each station represented a functional skill related to daily activities e.g. shuttle walking, sit to stand & step-ups. The circuit was completed twice (continuously), with 1 minute on each station & 30 seconds active transition between stations. Total CV duration = 30 minutes.
CV Cool Down
Graduated 10 minute cool down using walking or gentle stationary movements for those less mobile. Stretching also included.
Strength Conditioning Component
A combination of 3 – 4 strength exercises to promote upper limb mobility. 8 – 10 reps, focused on quality of movement, posture & symmetry.
Upper & lower limb stretches concluded the session. Stretches held for seconds to promote muscle lengthening & avoid adaptive shortening, especially around the shoulders.
Figure 2. Mean ±SD change between baseline ±110.50m & post-intervention ±119.92m assessments for 6MWD (m).
Conclusion
Once weekly exercise sessions for post-stroke survivors can place SBP & DBP into an anti-hypertensive range, despite no alterations in resting HR or medications. Functional capacity improved as indicated by an increase in 6MWD. Peak HR increased without any increase in Peak RPE suggesting improved exercise tolerance that may facilitate greater confidence in ability. TUG improved by approximately10% suggesting greater strength, speed & balance. GS improved for all participants, with the greatest change on their effected side. These results show a general improvement in health & functional parameters suggesting that long term stroke rehabilitation is effective in helping manage post-stroke recovery.
Limitations
There is a lack of post-stroke care to help patients suffering with long-term disability. This impacts on patient function, quality of life & an increased burden on the healthcare system. Exercise after stroke is not a nationally recognised pathway, as it is in other clinical populations e.g. cardiac & pulmonary rehabilitation. This presents a barrier to promotion & referral rates. If support is provided with  continued exercise rehabilitation, this may help individuals regain & sustain their independence. It also provides an effective secondary prevention strategy, helping to reduce costs & burden to the healthcare system. Ongoing stroke related appointments, e.g. physiotherapy, speech/language & occupational therapy resulted in numerous missed sessions. Illnesses, fatigue or lack of motivation also influenced attendance.
Further Research Recommendations
Stroke is a recovering condition, unlike a lot of neurodegenerative conditions. This study provides a compelling case for supportive therapies. Promising results following 12 weeks of exercise. Larger longitudinal studies are needed to quantify dose-response benefits of exercise to support the routine use in post-stroke recovery, secondary prevention & reduced co-morbidities.
Results
References
Faulkner, J., et al. (2014). Effect of early exercise engagement on cardiovascular and cerebrovascular health in stroke and TIA patients: Clinical trial protocol. Journal of Clinical Trials, 4,
Saunders, D.H., Greig, C. & Mead, G. (2014). Physical activity and exercise after stroke: review of multiple meaningful benefits. Stroke, 45, 12, 3742–3747.
Saunders, D. H., et al. (2016). Physical fitness training for stroke patients. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD DOI: / CD pub6.
Figure 1. Mean (±SD) change in SBP (mmHg) from baseline (±16.75) mmHg & post-intervention of 135 (±14.41) mmHg. The difference shown is a mean reduction of mmHg at post-intervention stage.