# Exercise as it relates to Disease/Physical activity guidelines, after a Stroke
## Physical Activity Guidelines, After a Stroke
### Background

Stroke is defined by The World Health Organization as a dysfunction caused by disturbances of the brain lasting over 24 hours and mainly affecting older people. Occurrence of stroke is due to blockage or bleeding of arteries supplying the brain with blood. Therefore, stroke can be categorized into ischemic or hemorrhagic stroke, respectively. Ischemic stroke is due to atherosclerotic plaque buildup in the arteries leading to blockage. Blood flow entering the outer space of the cranial cavity is known as a hemorrhagic stroke which in turn can cause damage to the brain. Neuronal death in the brain caused by stroke often leaves stroke survivors with brain damage. As the control centre of the nervous system, the normal functioning of the brain is crucial as it affects all cognitive activities including movement. As a result, voluntary muscle movement is impaired. This in turn causes immobility after stroke leading to low endurance for exercise including a reduction in cardiorespiratory health. Due to immobility, most stroke survivors lead a sedentary lifestyle. Exercise training interventions, such as aerobic and resistance training, have proven successful in improving cardiorespiratory fitness and muscle function as well as muscle strength , thus promoting improvement of symptoms and the prevention of a recurrent stroke.

### Physical Activity Guidelines for Stroke Survivors

A baseline assessment should be undertaken by a healthcare provider prior to beginning physical activity.

#### Exercise prescription considerations

* Safety factors:
    Patient clinical status, risk stratification category, exercise capacity, cognitive/psychological impairment that may result in non-adherence, and ischemic threshold.
* Associated factors:
    Patient musculoskeletal limitations, and personal fitness goals and motivation.

#### Precautions

Exercise discontinuation is dependent on diastolic blood pressure > 110 mm Hg, decreased systolic blood pressure with a reading of > 10 mm Hg during exercise, dyspnea, and ECG changes suggestive of ischemia.

#### Aerobic Exercise

Aerobic training aims to increase VO2 max due to decline after stroke. Sessions should include large muscle-group activities:
   * Arm ergometer
   * Combination upper/ lower extremity ergometer
   * Leg cycle ergometer.
   * Treadmill for walking
   * Cycle ergometer
   * Stepper
   * Stair climber
   * Rowing

##### Recommendations

* Warm up and cool down activities should be undertaken including stretching exercises to improve control of muscles and range of motion.
* Encouragement of gradual return to general activities of daily living (as evaluated and modified by healthcare professional).
* Pedometer wear (can enhance adherence; minimum of 10,000 steps).

#### Resistance Training

Types of equipments include:
   * Elastic bands
   * Wall pulleys
   * Light (0.45-2.27kg) cuff and hand weights
   * Light free weights (0.45-2.27kg).
   * Weight machines
Exercises should involve the major muscle groups. Refer to Further Reading for examples using the following major muscle groups:
   * Arms
   * Shoulders
   * Chest
   * Abdomen
   * Back
   * Hips
   * Legs

##### Recommendations

* Frequency: 2–3 days/week with separation of training the same muscle groups.
* Intensity: comfortable lifting of a load allowing 12-15 repetitions.
* Progression: increase gradually as adaptation to program occurs.

### Further reading

Hope: A Stroke Recovery Guide
ACSM's Guidelines for Exercise Testing and Prescription, 8th

### References

* 1 2 3 4 5 6 7 8 9 10 11 12 Lu, S.Y., Lin, K.F., and Cheng, C.M. (2005). Physical Activity and Stroke, Exercise Science and Fitness, 3, 55-60. Retrieved from http://www.scsepf.org/academic_current_2_no6.htm
* 1 2 Senes, S. (2006). How we manage stroke in Australia (AIHW cardiovascular health publication). Retrieved from the Australian Institute of Health and Welfare website: http://www.aihw.gov.au/publication-detail/?id=6442467815
* 1 2 3 Ehrman, J.K., Gordon, P.M., Visich, P.S. And Keteyian, S.J., (Eds.) (2009). Clinical Exercise Physiology, 2nd Ed., Human Kinetics.
* 1 2 3 Stroller, O., de Bruin, E.D., Knols, R.H., and Hunt, K.J. (2012). Effects of cardiovascular exercise early after stroke: systemic review and meta-analysis. BMC Neurology. doi:10.1186/1471-2377-12-45
* 1 2 3 4 5 6 7 Gordon, N.F., Gulanick, M., Costa, F., Fletcher, G., Franklin, B.A., Roth, E.J., & Shephard, T. (2004). Physical Activity and Exercise Recommendations for Stroke Survivors : An American Heart Association Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Journal of the American Heart Association, 109, 2031-2041. doi:10.1161/01.CIR.0000126280.65777.A4
* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Thompson, W.R., Gordon, N.F., & Pescatello, L.S., editors (2010). ACSM’s Guidelines for Exercise Testing and Prescription, 8th Ed., Lippincott Williams & Wilkins.
* 1 2 3 4 5 6 Durstine, J.L., & Moore, G.E., (Eds.) (2009). ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities, 3rd Ed., Human Kinetics.
* ↑ Macko, R.F., Smith, G.V., Dobrovolny, C.L., Sorkin, J.D., Goldberg, A.P., & Silver, K.H. (2001). Treadmill training improved fitness reserve in chronic stroke patients. Archives of Physical Medicine and Rehabilitation, 82, 879-884. doi:10.1053/apmr.2001.23853
* 1 2 3 4 Saunders DH, Greig CA, Mead GE, Young A. Physical fitness training for stroke patients. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD003316. DOI: 10.1002/14651858.CD003316.pub3.
* ↑ National Stroke Association. (2010). Hope: A stroke recovery guide. Retrieved from the National Stroke Association website: http://www.stroke.org/site/DocServer/hope4.pdf?docID=524