Cardiac Rehabilitation for Stroke Patients

Dina Brooks, Associate ProfessorUniversity of Toronto

Is it really survival of the fittest?

Why study stroke?

Leading cause of neurological

disability in adults

40,000 – 50,000 strokes per year

300,000 stroke survivors in Canada

60% have functional impairments

Physical impairments

Weakness Reduced range of motion Sensory changes Altered muscle tone Impaired coordination Reduced exercise capacity/fitness level

Impact of reduced fitness

Activities of Daily Living Altered walking

2/3 of stroke survivors have impaired walking function

1/2 of stroke survivors are unable to walk at all

Functional ambulation

The capacity to execute safe, efficient walking within time and environmental constraints encountered in everyday life

Functional Ambulation

Sensorimotor Control

Fitness

Cardiorespiratory and walking deficits may mutually reinforce one another

Impaired walking

Reduced cardiorespiratory fitness

Limits activitySedentary lifestyleFurther weakness

mechanical efficiency metabolic costs

HEALTH RELATED

QUALITY OF LIFE

Implications for function

In addition…..

75% with history of heart disease

50 - 84% have high blood pressure

40% have severe coronary artery

disease

Stroke risk factors

Hypertension

Smoking

Diabetes

Carotid stenosis

Atrial fibrillation

High cholesterol

Obesity

Physical Inactivity

Risk of second stroke or heart attack

Cardiovascular eventCardiovascular event

Cardiac Rehab-Up to 12 months

-Supervised exercise program

-Education

-Nutritional Support

Stroke Rehab-? 1-2 months

-Functional recovery

-Little exercise training

-Little formal education

Fitness in stroke:What does the literature say?

Exercise program feasible in stroke Results in:

o improved fitness level o reduced neurological impairment o enhanced lower extremity function

Changes in fitness levels from 8 to 23%

Not uniform effect throughout the groups

Fitness in stroke:What does the literature say?

Studies focus on exercise exclusively Generally less than three months

Why not use an established and common model of care (cardiac rehabilitation) and apply to the stroke population?

Cardiac rehabilitation model

Cardiac Rehab Up to 12 months Supervised exercise program Education Nutritional Support

Effects of Cardiac Rehabilitation for Individuals Following Stroke

Heart & Stroke Foundation of Ontario

Stroke Rehabilitation Special Competition #SRA 5977

Purpose

Establish feasibility of cardiac rehabilitation for individuals with stroke

Determine the effects on: Exercise, walking capacity and ability

Community re-integration

Quality of life

Risk factors for subsequent stroke

Design

Cardiac Rehab programBaseline3 months 6 months

Test 1 Test 2 Test 3 Test 4

Outcomes

Maximal exercise test Semi-recumbent cycle

ergometry

VO2peakPeak Work RatePeak Heart Rate

6-Minute Walk Test (6MWT) Stroke Impact Scale (SIS)

Risk factor profile Community reintegration

Intervention – Cardiac Rehab

Aerobic training 4-5 days / week

Resistance training 2 days / week

Education sessions

Training once a week at Centre

Exercise diary

Progress to date – Research

53 people have been recruited for the study

10 people were not entered, leaving 43 participants who enrolled into the study.

17 were able to walk without use of gait aids, 18 used a single point cane, 1 used a quad cane and 7 used a walker or rollator.

Preliminary resultsParticipant Demographics - AllParticipant Demographics - All

n=43 completed Baseline testing

Men / Women 30 / 13

Age 64 ± 13 (38-86)

Months post stroke 30 ± 28 (3-120)

Type: Isch / Hemorr / Unknown 28 / 10 / 5

R / L / Bilat hemisphere affected 16 / 25 / 2

Preliminary results

Changes during 3-month baseline periodChanges during 3-month baseline period(n=34)

0 months 3 months p

VO2peak, mlkg-1min-1

13.1 ± 4.8 14.9 ± 5.5 NS

Peak work rate, watts

59.9 ± 30 61.3 ± 33 NS

Peak heart rate, beats/min

110.8 ± 21 116 ± 23 NS

6-Minute Walk Test distance,

267.9 ± 135

273.9 ± 122

NS

Preliminary results

Changes following program completionChanges following program completion(n=27)

0 months 3 months

VO2peak, mlkg-

1min-1

14.9 ± 5.5 16.6 ± 5.5

Peak work rate, watts

61.3 ± 33 61.6 ± 31.9

Peak heart rate, beats/min

116 ± 23 114 ± 23

6-Minute Walk Test distance,

273.9 ± 132 299.4 ± 145.8

Preliminary results

No change in function during baseline 3 months

Attended 85% of scheduled classes

14% improvement in fitness level

9% reductions in BP

10% greater walking ability

6% lower relative stroke risk

Preliminary results

Subjects extremely satisfied with the program and wish to continue

Adaptation required for the program

Partners satisfied and wish to participate

Discussion

Aerobic and functional capacity in this population is low.

In the absence of formal community-based exercise, these measures remain unchanged.

Preliminary results suggest positive benefit to cardiorespiratory fitness, blood pressure and lower stroke risk

Ongoing data collection

How this research addresses the gap in stroke care?

Present rehab programs for Stroke ? 1-2 months Functional recovery Little exercise training Little formal education

That is not enough!

Impact on the community

It is time that we start using an established and common model of care (cardiac rehabilitation) in individuals with stroke

Key messages

Fitness levels very low in stroke patients

Rehabilitation should include a formal exercise component

Cardiac rehabilitation can be adapted for patients with stroke

AND WE WILL CHANGE PRACTICE!

Acknowledgements

Toronto Rehabilitation Institute Neuro Rehab and Cardiac Rehab Programs for their ongoing support and assistance

Research Team

William McIlroy and Dina Brooks

Scott ThomasMark BayleyPaul OhSandra BlackJim Salhas

Ada TangKathryn SibleyValerie Closson Cynthia DanellsHannah Cheung

Thank you!

Questions, comments…

Dina Brooks PhD

dina.brooks@utoronto.ca

Fitness in Community for Chronic Stroke

Purpose

To determine the proportion of fitness facilities in the Greater Toronto Area (GTA) that provide programs specifically developed for stroke survivors.

To identify the components and resources utilized by stroke specific fitness programs.

To determine perceived and actual barriers to offering fitness programs for stroke survivors.

Methods

Cross-sectional descriptive study Questionnaire was distributed to 784

fitness facilities in the GTA asking

Results

Of 213 respondents, 146 facilities reported that individuals with a chronic disability participated

62 facilities offered specific fitness programs for individuals with a chronic disability

26 with stroke-specific fitness programs

Findings

Typical stroke fitness programs operated as not-for-profit organizations, in large facilities

Specific acceptance criteria for stroke survivors to participate

Stroke-specific programs included aerobic, flexibility training and strengthening.