EXERCISE AFTER STROKESpecialist Instructor Training Course

L6Exercise after stroke:theory and evidence

Overview of Session• What is fitness training? • How randomised controlled trials are

designed• Systematic review of fitness training after

stroke (2004)• STARTER• Systematic review (2008)• Contraindications to exercise training

Learning outcomesAfter this session you should be able to:

• Describe what is known, and what is not known about the effects of exercise on stroke recovery.

• Discuss the strengths and limitations of the evidence for exercise after stroke

• Explain how the STARTER trial informs the current course

• State the recommendations for exercise after stroke

• List the contra-indications for exercise after stroke

Physical FitnessA set of attributes which people have or achieve,that confers the ability to perform physical activity;

Cardiorespiratory fitness (central and peripheral components)

Muscular strength (maximum force that can be generated byA muscle) and muscle power (rate at which muscular forceCan develop during a single muscle contraction)

Body composition (relative amounts of muscle and adiposetissue)

Physical Fitness Training

• Planned, structured regimen of regular physical exercise deliberately performed to improve one or more components of physical fitness (UHDHHS 1996)

• Physical fitness training after stroke may, in theory– Improve function– Reduce disability– Improve quality of life – Improve mood – Reduce fatigue– Reduce the risk of falls– Improve vascular risk factors and so reduce risk of

recurrent stroke and death

Design of a Randomised Controlled Trial

Patients

Baseline assessments

Randomised

Control Intervention

Assessments at end of interventions

Systematic reviews and meta-analyses

• Combines results of all trials of the same (or similar) intervention

• Provides a more precise measure of the

effectiveness (and risk) of an intervention than a single trial

• Widely used to guide clinical practice

Cochrane Systematic Review Physical fitness training after stroke

How?Extensive literature search and scrutiny of trials by 3Reviewers

We found; 12 trials (289 patients) BUTOnly 4 trials (60 patients) used ‘mixed’ trainingOnly 2 trials (33 patients) of adequate length to improvefitness Little information on feasibility More trials needed

Saunders Greig Young Mead 2004

What has happened since 2004?

• More trials have been performed, including our own STARTER trial

• A further systematic review and meta-analysis has been performed to determine the effect of physical fitness training on– Death – Dependence– Death and dependence– Disability– Physical function, physical fitness– Mood, fatigue – Whether benefits are retained after training complete

Aims of STARTER

• Determine feasibility of physical fitness training after stroke

• Obtain data about the effect of physical fitness compared with an attention control intervention

• Use STARTER results to design a bigger trial

STARTER designIndependently ambulatory, completed rehabilitation, no confusion or

contraindications to exercise?

Baseline assessments

Randomised

Fitness training Relaxation(both three times a week for 12 weeks)

Repeat assessments at end of interventions and 4/12

Assessments

• Disability

Nottingham extended ADL

Functional independence measure

• Function

Sit to stand

Timed up and go

Functional reach

Elderly mobility scale

Rivermead motor index

• Quality of life (SF-36)

• Mood (HADS)

• Physical fitness

Comfortable walking velocity

Walking economy

Leg extensor power

Important baseline characteristics

Exercise (n=32) Relaxation (n=34)

Age (mean, SD) 72 (10.4) 71.7 (9.6%)

Number (%) men 18 (56) 18 (53%)

TACSPACSLACS POCS uncertain

1 16 10 4 1

116980

Time between stroke and baseline (median, IQR)

Median (IQR) FIM

171 (55-287)

117.5 (114-121)

147.5 (78.8-235.5)

117.5 (112.8-122)

Fitness training intervention

• Devised by a Clinical Exercise Instructor in collaboration with a Specialist Stroke Physiotherapist (Mark Smith)

• Progressive in duration and intensity

• Warm up and cool down

• Cycling, marching, stepping, staircase, ball raises, chest press

• Resistance band exercises, sit-to-stand, arm press

Relaxation (attention control)

• Same venue as exercise class• Same instructor• 3 times a week, 12 weeks• Performed seated

– Deep breathing– Progressive muscle relaxation (no muscle

contraction)– During 12 weeks: progression

Feasibility: recruitmentAmbulatory patients assessed

(RIE, Liberton and AAH) 301Eligible 147 Agreed to take part 80

changed their minds -14developed contraindications -11died -1

Additional Recruitment (WGH) 12 Total 66

Feasibility: attendance

• Median number of classes attended was – 36 (IQR 30 to 36.75) for exercise– 36 (IQR 30.5 to 37) for relaxation

• At post-intervention assessment– 64 (97%) attended 1st post-intervention

assessment– 62 (94%) attended 2nd post-intervention

assessment

Outcomes in exercise group

Results are mean or median, * p<0.05 from baseline. No statistically significant changes in other variables

Baseline 1st post-intervention

2nd post-intervention

Role physical (SF36) 75.0 90.6* 78.1

General health (SF-36) 62 72* 63.5

Vitality (SF-36) 53.0 58.9* 55.3

Mental health (SF-36) 70 80* 75

Role emotional (SF-36) 87.5 100* 100

Functional reach (cm) 24.5 28.5* 26.5

Timed up-and-go (s) 12.3 11.4* 12.2

Sit to stand (s) 1.49 0.95* 1.11*

Leg extensor power (affected leg) (w/kg)

1.01 1.19* 1.18*

Comfortable walking speed m/s 0.66 0.73* 0.70

Walking economy (VO2 ml/kg/m)

0.128 0.126* 0.127

Outcomes in relaxation group

Mean or median, * p<0.05 from baseline.

No statistically significant changes in other variables

Baseline 1st post-intervention

2nd post-intervention

Mental health 70 80* 80*

Leg extensor power (unaffected leg)

1.12 1.26* 1.27*

Comfortable walking speed (m/s)

0.67 0.74* 0.74*

Differences between groups

1st post-intervention assessment Exercise better than relaxation

Quality of life: role physical

Physical function: timed up and go

Physical fitness: walking economy

2nd post-intervention assessment Exercise better than relaxation

Quality of life: role physical

Qualitative sub-study (benefits)

• Enjoyment– The class itself – Socialising – Getting out of the house

• Tuition– Endless praise for Irene (the exercise

instructor)– Participants felt ‘well looked-after’– Irene had a major role in the success of the

class

Qualitative sub-study (benefits)• Perceived benefits from both classes:

– Physical recovery– Getting back into a routine– Improved mood and wellbeing– Confidence

• Long term effects– Learning new skills– Practising at home– Attending other classes

To quote one participant…….

It was back in November and it was no joke

That was the time that I suffered a stroke….

Round came time for relaxation class

Others were there who’d been in the same boat…

The things we learned were useful and good….

The lady who ran the class is an excellent woman

Her voice is gentle and booming……

Thanks to the excellence of the wonderful Irene

Conclusions

• Trial design was feasible

• Exercise was more beneficial than relaxation for some outcomes

• Not all benefits were maintained long-term

• These results are included in the updated Cochrane systematic review and meta-analysis

Physical Fitness Training for Stroke Patients

Protocol first published: Cochrane Library, Issue 4, 2001

Review first published: Cochrane Library, Issue 1, 2004

Review updated: Cochrane Library, Issue 4, 2009

Cochrane Library, Issue 4, 2011

Cochrane Library, Issue 4, 2013

Systematic ReviewLiterature Search

ScreenedN=7508

RCTs includedN=45 n=2188

Not relevant N=7433

CardioN=22n=995

ResistanceN=8

n=275

MixedN=15n=918

MEDLINE, EMBASE, CINAHL, SPORTDiscuss

electronic databasesHand

searchingPending

referencesOther databases

and websites

13 new trials + 32 previouslyincluded

ExcludedN=29

RCTs OngoingN=16

Cannot be classifiedN=17

Number of patients randomised in trials of

physical fitness training after stroke

12 trials 2004 24 trials 2009 32 trials 2011 45 trials 20130

500

1000

1500

2000

2500

Research in exercise after stroke is increasing…

Trial participants

• Average age 64 years (i.e. younger than the median age of stroke onset of 72)

• 60% men, 40% women

• Majority were ambulatory

• Time since stroke: 8.8 days to 7.7 years

• PrimaryEffects of training on death & dependence unclear

Exercise improves of disability

• SecondaryExercise improves physical fitnessExercise improves walkingExercise improves balanceOther benefits unclear

ResultsPrimary & Secondary Outcomes

ResultsSecondary Outcome Measures

Outcome Cardio Strength Mixed

Adverse events ? ? ?

Physical fitness VO2 Strength ?

Walking ns

Function Balance ? ?

Quality of life ? ? ?

Mood ? ? ?

ResultsMaximum walking speed (5-10 metres)

Cycle Ergometer

Treadmill

Treadmill

Treadmill

Treadmill

Treadmill

Treadmill – backward walkingTreadmill – forward walking

Treadmill

TreadmillOver-ground walking

Circuit training including walking

Circuit training including walking

Treadmill

Treadmill + over-ground walking

Treadmill + over-ground walking

+ 7.37 m/min 95%CI [3.70 to 11.03]

Intervention Walking Outcome

End of intervention End of follow-up

N (n) Mean Difference (95% CI) Sig. N (n) Mean Difference (95% CI) Sig.

CardioTraining

MWS 13 (609) 7.37 m/min (3.70, 11.03) P < 0.0001 5 (312) 6.71 m/min (2.40, 11.02) P = 0.002

PWS 8 (425) 4.63 m/min (1.84, 7.43) P = 0.001 2 (126) 0.72 m/min (-6.78, 8.22) NS

6-MWT 10 (468) 26.99 metres (9.13, 44.84) P = 0.003 4 (233) 33.37 metres (-8.25, 74.99) NS

Resistance Training

MWS 4 (104) 1.92 m/min (-3.50 to 7.35) NS 1 (24) -19.8 m/min (-95.77, 56.17) NS

PWS 3 (80) 2.34 m/min (-6.77 to 11.45) NS - - -

6-MWT 2 (66) 3.78 metres (-68.56 to 76.11) NS 1 (24) 11.0 m/min (-105.95, 127.95) NS

MixedTraining

MWS - - - - - -

PWS 9 (639) 4.54 m/min (0.95 to 8.14) P = 0.01 4 (443) 1.60 m/min (-5.62, 8.82) NS

6-MWT 7 (561) 41.60 metres (25.25 to 57.95) P < 0.00001 3 (365) 51.62 metres (25.20, 78.03) P = 0.0001

ResultsMore Walking Performance Outcomes

ConclusionsPhysical fitness training after stroke

• Training improves disability, physical fitness, walking performance & balance

• Benefits are confined to cardiorespiratory and mixed training

• Benefits are exercise-specific • Further research is required

(e.g. optimal ‘prescription’, long-term benefits, risks, costs, non-ambulatory patients)

What we don’t know• Effect of fitness training on many important

outcomes e.g. mood, fatigue, falls, disability, dependence and death

• Effect on vascular risk factors• Optimum type of training• Optimum mode, frequency, intensity, duration• Timing (e.g. in-patient, after usual rehab)• Whether any benefits are retained longer-term• Feasibility of exercise delivery to non-ambulatory

patients• Might some benefits be mediated by social

interaction? • How to ensure people continue exercise after

initial training programme

Implications for exercise classes after stroke

• Exercise training may improve walking ability if cardiorespiratory training is included

• Disability may be improved by cardiorespiratory training or mixed training

• Effects of strength training alone are uncertain

• Further research is needed

Absolute contraindications to exercise training

• Uncontrolled angina• Recent myocardial infarction• Resting systolic blood pressure

>180 mmHg or resting diastolic BP of >100mm Hg

• Significant drop in BP during exercise

• Uncontrolled resting tachycardia >100 beats per minute

• Unstable or acute heart failure• New or uncontrolled arrhythmia• Severe stenotic or regurgitant

valvular heart disease• Hypertrophic obstructive

cardiomyopathy• Third degree heart block • Acute aortic dissection • Acute myocarditis or

pericarditis

• Unstable diabetes• Uncontrolled visual or

vestibular disturbances• Recent injurious fall without

medical assessment• Proven inability to comply with

the recommended adaptations to the exercise programme and inability to maintain an upright posture in sitting

• Febrile illness • Extreme obesity, with weight

exceeding the recommendations or the equipment capacity (usually >159kg [350 lb.])

• Acute pulmonary embolus or pulmonary infarction

• Deep venous thrombosis

Relative contraindications

• Cardiomyopathy • Moderate stenotic valvular heart disease • Complex ventricular ectopy • Left main coronary artery stenosis • Electrolyte imbalance • Tachyarrhythmias or bradyarrhythmias• High degree atrio-ventricular block• Mental or physical impairment leading to inability

to exercise adequately

Acknowledgements

• Dr Dave Saunders, Lecturer, University of Edinburgh

• Dr Carolyn Greig, Senior Research Fellow, University of Edinburgh

• Professor Archie Young, Emeritus Professor, University of Edinburgh

• Hazel Fraser and Brenda Thomas Cochrane Stroke Group http://www.dcn.ed.ac.uk/csrg

Essential Reading

Further detail about the topics discussed in this

session can be found in section L6 of the

course syllabus.