Stroke is one of the leading causes of long term disability in India. It has emotional, psychological, physical and financial effects on the stroke survivor as well as his/her family.
Stroke survivors are predisposed to a sedentary lifestyle that limits performance of activities of daily living, increased risk of falls and heightened risk for recurrent stroke and cardiovascular disease. Activity limitations (also referred to as “disabilities”) are manifested by reduced ability to perform daily functions, such as dressing, bathing, or walking. The magnitude of activity limitation is generally related to but not completely dependent on the level of body impairment (ie, severity of stroke). Other factors that influence level of activity limitation include intrinsic motivation and mood, adaptability and coping skill, cognition and learning ability, severity and type of preexisting and acquired medical comorbidity, medical stability, physical endurance levels, effects of acute treatments, and the amount and type of rehabilitation training. All the above effects create a vicious circle of further decreased activity and greater exercise intolerance, leading to secondary complications such as reduced cardiorespiratory fitness, muscle atrophy, osteoporosis, and impaired circulation to the lower extremities in stroke survivors. In addition, a diminished self-efficacy, greater dependence on others for activities of daily living, and reduced ability for normal societal interactions can have a profound negative psychological impact
Goals of Physical activity / Exercise
Traditionally, the physical rehabilitation of individuals typically ended within several months after stroke because it was believed that most if not all recovery of motor function occurred during this interval. Nevertheless, recent research studies have shown that aggressive rehabilitation beyond this time period, including treadmill exercise with or without body weight support, increases aerobic capacity and sensorimotor function. The three major rehabilitation goals for stroke patients are preventing complications of prolonged inactivity, decreasing recurrent stroke and cardiovascular events, and increasing aerobic fitness.
Preventing complications of prolonged physical inactivity
The stroke patient needs to initiate a physical conditioning regimen designed to regain prestroke levels of activity as soon as possible. For inpatients, simple exposure to orthostatic or gravitational stress (ie, intermittent sitting or standing) during hospital convalescence has been shown to prevent much of the deterioration in exercise tolerance that normally follows a cardiovascular event or intervention. Shortly after hospital discharge, the continuum of exercise therapy may range from remedial gait retraining in hemiparetic stroke patients to supervised or home-based walking or treadmill training programs.
Prevent recurrent Stroke and Cardiovascular events
A reduction of risk factors can decrease the incidence of recurrent strokes and cardiac events. An aerobic conditioning program can enhance glucose regulation and promote decreases in body weight and fat stores, blood pressure (particularly in hypertensive patients), and levels of total blood cholesterol, serum triglycerides, and low-density lipoprotein (LDL) cholesterol. Exercise also increases high-density lipoprotein (HDL) cholesterol and improves cardiac function.
Increasing aerobic fitness
Evidence is accumulating that stroke risk can be reduced with regular leisure-time physical activity in men and women of all ages. It has been proven that men in the moderate- and high-fitness groups had a 63% and 68% lower risk of stroke death, respectively, than men who were in the lowest-fitness group at baseline. Moreover, the inverse association between aerobic fitness and stroke mortality remained even in the presence of cigarette smoking, alcohol consumption, obesity, hypertension, diabetes mellitus, and a family history of heart disease.
It is essential that the stroke survivor carries out exercise under the close supervision of qualified medical personnel.
Stroke survivors and caregivers please note:
- Recurrent stroke and cardiovascular disease are the leading causes of mortality in stroke survivors.
- Physical activity remains a cornerstone in the current armamentarium for risk factor management for the prevention and treatment of stroke and cardiovascular disease.
- Activity intolerance is common among stroke survivors, especially the elderly. Their sedentary lifestyle puts them at risk for recurrent stroke and cardiovascular disease.
- Stroke patients achieve significantly lower maximal workloads and heart rate/blood pressure responses than controls during progressive exercise testing.
- Many factors influence activity level after stroke, including physical, mental, and emotional status. Stroke patients may be more disabled by associated cardiac disease than by the stroke itself.
- Energy expenditure during walking in hemiplegic patients varies with degree of altered body structure and function but is generally elevated, often up to 2 times that of able-bodied persons walking at the same submaximal speed.
Benefits of aerobic conditioning:
- Stroke survivors can benefit from counseling on participation in physical activity and exercise training.
- Research studies show that aggressive rehabilitation beyond the usual 6-month period increases aerobic capacity and sensorimotor function.
- An aerobic exercise program can improve multiple cardiovascular risk factors and thereby have important implications for the medical management of stroke survivors.
- Evidence is accumulating that stroke risk can be reduced with regular leisure-time physical activity in multiethnic individuals of all ages and both sexes. Evidence now suggests that the exercise trainability of stroke survivors may be comparable to that of age-matched healthy counterparts.
- Extrapolation of what is known about the training effects of regular exercise by able-bodied individuals suggests that certain levels of exercise that are achieved during many stroke rehabilitation programs may improve aerobic fitness.
Preexercise evaluation:
- It is recommended that all stroke survivors undergo a preexercise evaluation (complete medical history and physical examination, usually including graded exercise testing with ECG monitoring) before they initiate an exercise program.
- When undergoing exercise testing, the testing mode should be selected or adapted to the needs of the stroke survivor (eg, use of handrails, arm cycle ergometry, arm-leg or leg cycle ergometry).
Recommendations for exercise programming:
- Treadmill walking is highly advantageous as the aerobic exercise mode, with inclusion of resistance, flexibility, and neuromuscular training.
- The combination of comorbidities, neurological deficits, and emotional barriers unique to each stroke survivor requires an individual approach to safe exercise programming.
- For patients unable to perform a graded exercise test, light-to-moderate rather than vigorous exercise should be prescribed, with a greater training frequency, duration, or both to compensate for the reduced intensity.
- Subsets of stroke survivors (eg., those with depression, fatigue syndrome, poor family support, or communication, cognitive, and motor deficits) will require further evaluation and subsequent specialization of their rehabilitation program.
- To enhance exercise compliance, the issues of family support and social isolation need to be addressed and resolved.
- Physical activity and exercise training recommendations for stroke survivors should be viewed as one important component of a comprehensive stroke and cardiovascular risk reduction program.
Source: Circulation 2004;109:2031-2041