LINKING EVIDENCE AND PRACTICE

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1 Physical Fitness Training After Stroke Ada Tang, Janice J. Eng LEAP LINKING EVIDENCE AND PRACTICE <LEAP> highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions medications, surgery, education, nutrition, exercise and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature. 1 Each article in this PTJ series summarizes a Cochrane review or other scientific evidence resource on a single topic and will present clinical scenarios based on real patients to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on physical fitness interventions for individuals with stroke. This population is at higher risk for sustaining recurrent stroke, as these individuals commonly have cardiovascular comorbidities and risk factors, as well as mobility limitations that contribute to sedentary behaviors. Addressing the decline in fitness after stroke is an important consideration for physical therapists working with individuals with stroke. This article summarizes the results of the Cochrane review Physical Fitness Training After Stroke by Brazzelli and colleagues 2 and presents a clinical scenario, based on a real patient, to illustrate how the results from this systematic review can be used to directly inform clinical decisions in physical therapy. Can physical fitness training after stroke improve walking and cardiorespiratory fitness in this population? Find the <LEAP> case archive at collection/leap. Stroke is one of the leading causes of mortality and disability, with major socioeconomic impact, particularly in developed countries. 3 There is a twofold higher risk of cardiac-related mortality compared with agematched controls, 4 and the 5- and 10-year rates for recurrent stroke are 26% and 40%, respectively. 5 Interventions that target modifiable cardiovascular risk factors, such as hypertension, smoking status, body composition, and physical activity, may reduce the burden of stroke. 6 For the general population, the benefits of improved physical fitness on a myriad of health outcomes are well established. Physical fitness includes components such as cardiorespiratory fitness, muscle strength and endurance, flexibility, and body composition. 7 Higher levels of fitness are associated with reduced risk for all-cause and cardiovascularrelated mortality, 8,9 cardiovascular disease, 10 and stroke, 11 and aerobic exercise training has been shown to improve a number of vascular risk factors After stroke, all areas of physical fitness may be directly affected by the neurological lesion, or may be a result of long-term sedentary behaviors. Muscle weakness, or paresis, is the hallmark impairment of stroke, 15 but altered muscle tone can affect range of motion, and cardiorespiratory fitness is compromised to 60% of normative values. 16,17 Although stroke rehabilitation interventions have historically focused on remediating neurological impairments and improving functional independence, physical therapists are now recognizing the impact of compromised physical fitness on rehabilitation outcomes and risk for future cardiovascular events. Engaging in regular physical activity to improve fitness is an important strategy for reducing sedentary behaviors that otherwise may compound poststroke limitations. 17 In 2004, the American Heart Association published physical activity and exercise guidelines for individuals with stroke 18 based on the limited amount of research evidence that existed at that time. Since then, there has been a steady growth of research evidence examining the effects of physical fitness training after stroke. Brazzelli and colleagues 2 have performed an updated Cochrane systematic review of randomized controlled trials that evaluated the effectiveness and safety of physical fitness training after stroke and extended the search from their previous review to include trials published up to July Thirty-two trials involving 1,414 participants investigated physical fitness training that was initiated either in the immediate poststroke period (average 8.8 days) or later (average 7.7 years). The primary review outcomes were case fatality, death, or dependence and disability. Secondary outcomes included occurrence of adverse effects, effects on vascular risk factors, physical (cardiorespiratory or musculoskeletal) fitness, mobility, physical function, health status and quality of life, and mood. The interventions were categorized according to: (1) cardiorespiratory training to improve cardiorespiratory fitness, (2) resistance training to increase muscle strength or power, or (3) mixed training, a combination of cardiorespiratory and resistance January 2014 Volume 94 Number 1 Physical Therapy f 9

2 Table 1. Summary of Key Results a All relevant studies up to July 2010 were included. Thirty-two trials involving 1,414 participants were included. Mean age of participants was 67 years, and average time from onset of stroke ranged from 8.8 days (ie, while still in the hospital) to 7.7 years (ie, occurring after hospital discharge). Most studies recruited participants from hospital or community care and included participants capable of ambulation. One trial included nonambulatory participants, and 3 trials used a combination of ambulatory and nonambulatory participants. Three types of interventions were included: CR training in 14 trials with 651 participants utilizing a variety of modalities, including circuit, aquatic exercise, ergometry, or treadmill training. Resistance training in 7 trials with 246 participants utilizing weights, exercise machines, or elastic devices. Five studies focused on lower body training, 1 on upper body training, and 1 on combined upper and lower body training. Most trials were 12 weeks in duration. Mixed training (combination of cardiorespiratory and resistance training) in 11 trials with 517 participants utilizing a broad range of training modalities (circuit training, walking or treadmill training, resistance training). Most studies were 12 weeks in duration. Outcomes were considered separately for physical training that commenced earlier (mean 8.8 days) and physical training that commenced later (mean 7.7 years) after stroke. Where reported, attendance ranged from 65% to 100%, and program adherence was described as high. Risk of bias: Overall, trials were of modest quality, limited by small sample sizes and high attrition at retention follow-up. Many studies did not use blinded assessors or report on methods for sequence generation or attendance rates. Primary outcomes CR training, mixed training, resistance training: No differences between exercise and control groups for case fatality or disability. Effects of training on death or dependence were not reported in any trial. Secondary outcomes CR training: More effective than control intervention for improving V O2 peak (4 studies, MD 2.14 ml kg 1 min 1, 95% CI ), preferred gait speed (4 studies, MD 4.68 m/min, 95% CI ) and maximal gait speed (7 studies, MD 8.66 m/min, 95% CI ), and 6MWT distance (4 studies, MD m, 95% CI ). No difference between CR training and control intervention on systolic or diastolic blood pressure (4 studies). Mixed training: More effective than control intervention for improving V O2 peak (1 study, MD 0.99 ml kg 1 min 1, 95% CI ), preferred gait speed (8 studies, MD 2.93 m/min, 95% CI ), and 6MWT distance (3 studies, MD m, 95% CI ). Resistance training: More effective in improving composite measures of muscle strength than control intervention (2 studies, SMD 0.58, 95% CI ). a CR cardiorespiratory, V O2 peak peak oxygen consumption, MD mean difference, 95% CI 95% confidence interval, 6MWT Six-Minute Walk Test, SMD standardized mean difference. training. Table 1 summarizes the findings of this review. Take-Home Message From this Cochrane review, 2 there is clear evidence to recommend cardiorespiratory and mixed training for improving walking speed (at preferred and maximal paces) and walking capacity. Studies that incorporated walking into the program demonstrated greater benefit to walking parameters, and improvements in walking appear to have long-standing effects beyond completion of the training program, as benefits were retained at follow-up. 2 There is some evidence to support the use of cardiorespiratory or mixed training after stroke to improve aerobic capacity and insufficient data to draw conclusions regarding the effects of fitness interventions on disability, death and dependence, vascular risk factors, physical function, quality of life, and mood outcomes. 2 Case #20: 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 [Glaxo SmithKline, 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/m 2 ). On examination, the physical therapist noted that Mr Chan exhibited residual right-sided weakness. The patient ambulates independently indoors and outdoors with a singlepoint 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 f Physical Therapy Volume 94 Number 1 January 2014

3 m/s, 6MWT distance m), they are nonetheless compromised, representing 64% 19 and 55% 20 of agematched 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 review 2 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 colleagues 2 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 <LEAP> Case #20 Physical Fitness Training for Patients With Stroke Table 2. Frequency, Intensity, Time, and Type (FITT) Prescription for Mr Chan a Frequency Intensity b Time Type Three times per week, with twice-weekly outpatient therapy sessions supplemented by once-weekly home exercise (described below). Target HR range was calculated as: 40% 80% HR reserve [(peak HR from the exercise test resting HR) 40% 80% resting HR] [(115 68) 40% 80% 68] bpm. Training started at the lower end of the target range (ie, 87 bpm), and progressed by 5% HR reserve every 2 weeks, as tolerated, up to 70% 80% HR reserve. 26 A strapless continuous HR monitor was worn on the forearm (e-pulse2, Impact Sports Technologies, San Diego, California). To start, Mr Chan was instructed to maintain RPE between 11 ( fairly light ) and 14 (above 13 [ somewhat hard ] but less than 15 [ hard ]) on the 6 20 scale. Target duration was 30 minutes. Mr Chan could tolerate only one 10-minute bout of exercise in the first week. Each week, exercise duration was increased by 5 to 10 minutes until he achieved 30 minutes of continuous exercise. The physical therapist felt that, initially, cycling was a safer option due to the potential for gait instability (recent fall) and would be more effective in achieving and maintaining target HR than through walking alone. Upright and semirecumbent stationary exercise cycles were readily available in the therapy area. Some exercise cycles were equipped with special adapted footplate pedals, but Mr Chan did not need to use these devices. Five minutes of treadmill walking was introduced into the second week of the exercise program. As Mr Chan s walking tolerance improved, the proportion of exercise performed on the stationary cycle was reduced, and walking duration increased. For at-home sessions, activities such as marching on the spot, repeated sit-to-stand maneuvers from a stable chair, and step-ups onto the lowest stair were performed and progressed by increasing the number and speed of repetitions, lowering the chair height, or raising the step height. 26 As Mr Chan s walking capacity improved, he started to incorporate walking into his at-home program. a HR heart rate, RPE rating of perceived exertion. b If exercise testing were not available, predictive equations may be used to estimate maximal HR (eg, age-predicted maximal HR (0.69 Age) 27 ), which then can be used to calculate %HR reserve. Additional consideration would be given to individuals taking beta-blocker medications that can blunt HR response to exercise by 20% 30%. Because predictive equations have not been valued for individuals with stroke, RPEs become more important to supplement the HR prescription to ensure that exercise remains within tolerable ranges. exercise training. Peak oxygen consumption (V O2 peak) 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 values 20 ). This improvement aligns with the conclusions from the Cochrane review, and the increase is greater than the 51-m January 2014 Volume 94 Number 1 Physical Therapy f 11

4 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 m/s) and not dissimilar to Mr Chan s results. This MD also is less than the values of to 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 twiceweekly 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. A. Tang, PT, PhD, School of Rehabilitation Science, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada. J.J. Eng, PhD, BSc(PT/OT), Department of Physical Therapy, University of British Columbia, Wesbrook Mall, Vancouver, British Columbia, Canada V6T 1Z3. Address all correspondence to Dr Eng at: janice.eng@ubc.ca. The authors acknowledge support from the Canadian Institutes of Health Research (CIHR) (MOP ). Dr Tang was supported by CIHR (MFE-98550) and the Michael Smith Foundation for Health 12 f Physical Therapy Volume 94 Number 1 January 2014

5 Research (MSFHR) (ST-PDF-03003(11-1) CLIN). Dr Eng is supported by CIHR (MSH ) and the MSFHR. [Tang A, Eng JJ. Physical fitness training after stroke. Phys Ther. 2014;94:9 13.] 2014 American Physical Therapy Association Published Ahead of Print: June 27, 2013 Accepted: June 21, 2013 Submitted: August 26, 2012 DOI: /ptj References 1 The Cochrane Library. Available at: index.html. 2 Brazzelli M, Saunders DH, Greig CA, Mead GE. Physical fitness training for stroke patients. Cochrane Database Syst Rev. 2011;(11):CD Feigin VL, Lawes CM, Bennett DA, Anderson CS. Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. Lancet Neurol. 2003;2: Adams RJ, Chimowitz MI, Alpert JS, et al. Coronary risk evaluation in patients with transient ischemic attack and ischemic stroke: a scientific statement for healthcare professionals from the stroke council and the council on clinical cardiology of the American Heart Association/American Stroke Association. Stroke. 2003;34: Mohan KM, Wolfe CD, Rudd AG, et al. Risk and cumulative risk of stroke recurrence: a systematic review and meta-analysis. Stroke. 2011;42: O Donnell MJ, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet. 2010;376: American College of Sports Medicine. ACSM s Guidelines for Exercise Testing and Prescription. Philadelphia, PA: Lippincott Williams & Wilkins; Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med. 2009;43: Berry JD, Willis B, Gupta S, et al. Lifetime risks for cardiovascular disease mortality by cardiorespiratory fitness levels measured at ages 45, 55, and 65 years in men: The Cooper Center Longitudinal Study. J Am Coll Cardiol. 2011;57: Mora S, Cook N, Buring JE, et al. Physical activity and reduced risk of cardiovascular events: potential mediating mechanisms. Circulation. 2007;116: Lee CD, Folsom AR, Blair SN. Physical activity and stroke risk. Stroke. 2003;34: Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med. 2002;136: Kelley GA, Kelley KS, Franklin B. Aerobic exercise and lipids and lipoproteins in patients with cardiovascular disease: a meta-analysis of randomized controlled trials. J Cardiopulm Rehabil. 2006;26: ; quiz ; discussion Boule NG, Haddad E, Kenny GP, et al. Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA. 2001;286: Bohannon RW. Muscle strength and muscle training after stroke. J Rehabil Med. 2007;39: MacKay-Lyons MJ, Makrides L. Exercise capacity early after stroke. Arch Phys Med Rehabil. 2002;83: Rimmer JH, Wang E. Aerobic exercise training in stroke survivors. Top Stroke Rehabil. 2005;12: Gordon NF, Gulanick M, Costa F, et al. Physical activity and exercise recommendations for stroke survivors. Stroke. 2004; 35: Bohannon RW, Williams Andrews A. Normal walking speed: a descriptive metaanalysis. Physiotherapy. 2011;97: Enright PL, Sherrill DL. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med. 1998; 158: Flansbjer UB, Holmback AM, Downham D, et al. Reliability of gait performance tests in men and women with hemiparesis after stroke. J Rehabil Med. 2005;37: Tilson JK, Sullivan KJ, Cen SY, et al. Meaningful gait speed improvement during the first 60 days poststroke: minimal clinically important difference. Phys Ther. 2010;90: Fulk GD, Ludwig M, Dunning K, et al. Estimating clinically important change in gait speed in people with stroke undergoing outpatient rehabilitation. J Neurol Phys Ther. 2011;35: Shaw K, Gennat H, O Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database Syst Rev. 2006;(4): CD Stoller O, de Bruin ED, Knols RH, Hunt KJ. Effects of cardiovascular exercise early after stroke: systematic review and metaanalysis. BMC Neurol. 2012;12: Pang MYC, Eng JJ, Dawson AS, et al. A community-based fitness and mobility exercise (FAME) program for older adults with chronic stroke: a randomized, controlled trial. J Am Geriatr Soc. 2005;53: Gellish RL, Goslin BR, Olson RE, et al. Longitudinal modeling of the relationship between age and maximal heart rate. Med Sci Sports Exerc. 2007;39: January 2014 Volume 94 Number 1 Physical Therapy f 13