E-Rehabilitation: Aerobic Resistance Training for Stroke Survivors

Seven million Americans are stroke survivors and another four million Americans are expected to have strokes by 2030.1 Nearly 800,000 strokes occur annually and of these, 25% occur after a previous stroke or transient ischemic attack (TIA).2 Put another way, stroke recurrence affects 30% of stroke survivors.3 Given the high burden of stroke among stroke survivors, preventing recurrence is a top priority for post-stroke and post-TIA management.

Stroke survivors must cope with impairments in functioning that can range from facial droops to hemiparesis and aphasia. These physical challenges mean that even four years after stroke, 71% of survivors feel they have not completely recovered from the stroke.4 The peak oxygen cost (VO2) of participating in activities of daily living such as walking is higher in stroke survivors six months after stroke than able-bodied individuals.5,6 This increased energy cost is related to decreased cardiorespiratory reserve, changes in tissue composition, and gait deviation and asymmetry.5,6 The exhaustion point for hemiparetic stroke survivors falls within the range of aerobic fitness required to perform activities of daily living (3-5 METS [Metabolic Equivalents]).6 Small increases in aerobic capacity would therefore translate into the ability to perform activities of daily living.6

The American Heart Association (AHA) and American Stroke Association issued guidelines in 2014 recommending physical activity and exercise to improve stroke survivors' functional ability, quality of life, and morbidity of stroke recurrence.3 It is the goal of this study to improve physical activity adherence in stroke survivors and thereby improve their cardiorespiratory reserve and reduce depression. Secondary variables to be examined include functional ability, balance, blood pressure, body mass index (BMI), rates of cerebrovascular and cardiovascular events, and mortality.

Exercise-based cardiac rehabilitation post-stroke or post-TIA Cardiac rehabilitation care post-discharge for stroke survivors is not established standard of practice. Several groups have been evaluating the efficacy of comprehensive cardiac rehabilitation, as provided to patients after acute MI, in post-stroke populations. This intervention has been shown to be cost effective in post-MI care, reducing healthcare cost overall (attributed to fewer re-admissions) and per quality-adjusted life year.12 Several groups have conducted small-scale trials of cardiac rehabilitation among TIA and stroke patients with promising improvements in cardiovascular fitness outcomes.13-16 Aerobic exercise for rehabilitation after stroke has been evaluated in small randomized controlled trials.6,17

One group conducted a randomized controlled trial of a comprehensive cardiac rehabilitation program in chronic stroke patients after ischemic events.14 Their intervention was twice weekly, supervised exercise on cycle ergometers (upper or lower body) to 50-60% maximal heart rate.14 At the end of the ten-week program, subjects in the intervention arm showed significant improvements in cardiovascular fitness as measured by peak oxygen consumption (VO2) and rating of perceived exertion (RPE) after three minutes of exercise.14 Self-reported depression and anxiety scores also improved in the intervention arm, though health-related quality of life did not.14 The same group is now conducting a larger clinical trial called Cardiac Rehabilitation Adapted For Transient Ischemic Attack and Stroke (CRAFTS) expanding on the results of the earlier pilot.13,14