# Exercise as it relates to Disease/Chronic Stroke Survivors - How can Exercise Help?

This page has been created for the purpose of analyzing the article "Muscle Strengthening and Physical Conditioning to Reduce Impairment and Disability in Chronic Stroke Survivors" by Teixeira-Salmela, L., Olney, S., Nadeau, S., & Brouwer, B. (1999), for the University of Canberra unit Health Disease and Exercise.

## Research Background

A stroke is defined is a “focal neurological deficit secondary to a vascular event lasting more than 24hrs”. This means that part of the brain has had a sudden loss of blood supply, and results in infarction (cell death). There are two main causes, a blocked artery known as Ischemic stroke and accounts for 85% of stroke cases, or the leaking or bursting of a blood vessel within the brain itself, a Haemorrhagic stroke. Due to this cell death, many cognitive and mechanical impairments are a result leading to further disabilities.
Disabilities such as paralysis of limbs, loss of muscle control (which can affect speech and swallowing capabilities), memory loss or cognitive difficulties, pain, behavioural and emotional changes are to name a few. One of the most debilitating of these is the loss of muscle control and paralysis. This in turn affects standing, walking, balance and mobility and affects daily living, meaning that daily personal and household tasks cannot be performed.
Research has been undertaken to find the best and most cost-effective ways to rehabilitate chronic stroke survivors. Muscle strength training, and general physical conditioning are at the forefront of this research, looking for the best ways to improve motor control, gait patterns and functionality, to reduce the risk of falls and improve quality of life. This enables the stroke community to recover at a faster rate and gain back independence. The purpose of this by Teixeira-Salmelam Onley, Nadeau and Brouwer are to look at the effects of a combined muscle strengthening and physical conditioning program in reducing the impairment and disabilities mentioned above in chronic stroke survivors.

## Where is this Research From?

This study was conducted by Teixeira-Salmela from the Universidade Federal de Minas Gerais, Brazil and Olney, Nadeau and Brouwer from the School of Rehabilitation Therapy, Queens University Canada. Teixeira–Salmela is a well-known researcher, having conducted previous studies such as “Effects of Muscle Strengthening and Physical Conditioning of Temporal, Kinematic and Kinetic Variables During Gait in Chronic Stroke Survivors”.
This article was published in the Archives of Physical Medicine and Rehabilitation, the official journal for the American Congress of Rehabilitation Medicine (ACRM). This is an organisation that publishes original, peer reviewed research and clinical reports to maintain knowledge in the rehabilitation processes.
The subjects involved were 13 community dwelling stroke survivors who suffered a stroke 9 months (or more) prior to this intervention. This is a very small research group, meaning the results only reflect accurately to this community of people, however despite this, the results can be applied to the wider population with its overall results due to the generalization of the program.
This study is a volunteer study, with those who had other medical conditions and impairment being excluded. A drawback of being a volunteer study, is that only those with motivation to participate were involved in this program. This in turn may have skewed the final Quality of Life results, as any improvement been seen as a large improvement.

## What kind of Research is this?

This research was a qualitative study involving a randomized pre-and post-test control group then a single group pre-/post-test, with 13 participants total. By the end of this study, both the control and test group underwent the program, creating more data to be analysed. This means that there was more data to work with and results are able to be measured and shown with ease and more accurately. The major drawback of this is the small participant size as mentioned above.

## What Where the Research Methods?

The design of this testing method was a randomized pre/post-test undertaken, then allocation to treatment and control groups. The treatment group undertook a 10-week training program, and then both groups were retested. After this testing, the baseline control also undertook the same 10-week program with retesting at its competition. This method of testing creates more data for the researches, creating less error and variation in the results. It insures that all 13 participants underwent the program, rather than only half, which would make the participant size even smaller.
| Measurements Taken |
| Functional Performance | Functional Walking Speed |
| | Rate of Stair Climbing |
| | Human Activity Profile(HAP) |
| Lower Extremity Muscle Tone | Cybex 2 Isokinetic Dynamometer |
| Lower Extremity Muscle Strength | Pendulum Test |
| Quality of Life | Nottingham Health Profile |
The Human Activity Profile and the Nottingham Health Profile have been proven to be an accurate way to test the activity levels with people with chronic conditions and quality of life respectively.
The training program itself consisted of supervised exercise sessions conducted three mornings a week for 10 weeks, lasting 60-90 mins. Each session involved a warm up, aerobic exercises (walking plus stepping or cycling), strength training and a cool down period. Emphasis was placed on the lower extremity muscles and trunk flexibility.

## What Where the Basic Results?

| Testing | Improvements |
| Functional Walking Speed | 30.7% |
| Rate of Stair Climbing | 37.4% |
| Perceived Abilities (HAP) | 38.2% |
| Lower Extremity Strength | 42.3% (above baseline measures) |
| Lower Extremity Muscle Tone | No improvement |
| Quality of Life (REFRENCE NHP) | 77.8% |
Overall a significant improvement in the reduction of impairment and disability was observed. The improvement in Quality of Life assessment can be associated with these improvements, for as the physical capabilities are improved, more independence and confidence is gained for that individual. There was no improvement in lower extremity muscle tone, which can be associated with the age of this target group, as the elderly population have lower muscle mass and tone associated in general.

## What Conclusions can we take from this Research?

From the results of this study the researchers concluded that there was a “significant improvement in all measures of impairment and disability”. This statement is not quite accurate in that there was no improvement in the Lower Extremity Muscle Tone, however in all other areas there were significant changes.
Considerations taken into account were the volunteer status of the subjects, meaning that motivation and commitment were higher and this may have affected the quality of life score. The age and health status of the participants also had to be taken into account, those with cardiac risk or other non-stroke related disabilities were excluded. This reduced the treatment size as most stroke patients have other health problems at the same time.
This study has shown that muscle strengthening and physical conditioning is an effective tool to use for Chronic Stroke patients. It improved gait speed, rate of stair climbing and general functional performance. This in turn has led to an improvement in Quality of life and total strength of major muscles groups.
This program developed is and effective tool to use for the chronic stroke community, in reducing disability and functional impairments. Further research should be undertaken to develop this program to target exercises and program types that work best, both in general and specific stroke populations. Research with a larger scale and size is also needed, so that the larger cohort can be applied more effectively and reliably to the wider chronic stroke population.

## Practical Advice

A muscle strengthening and physical conditioning program has been shown to be a beneficial way to improve the motor control and abilities of chronic stroke survivors. These programs are a useful tool for rehabilitation industry, however should be tailored to fit all individuals when undertaken.
Further research needs to be undertaken to both broaden the programs to a wider population as well as into specific areas of impairments.

## Further Information and Resources

Further information about strokes and similar studies:
World Health Organisation; Stroke: a global response is needed.
A study by Teixera-Salmela, Nadeau et al showed similar results, with increases in gait speed and walking speed as well.
Muscle Strength and Muscle Strengthening After Stroke by Richard W. Bohannon
Motor Recovery After Stroke

## References

* 1 2 3 Teixeira-Salmela, L., Olney, S., Nadeau, S., & Brouwer, B. (1999). Muscle strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivors. Archives Of Physical Medicine And Rehabilitation, 80(10), 1211-1218. http://dx.doi.org/10.1016/s0003-9993(99)90018-7
* ↑ Stroke - Symptoms and causes. (2017). Mayo Clinic. Retrieved 7 September 2017, from http://www.mayoclinic.org/diseases-conditions/stroke/symptoms-causes/dxc-20117265
* ↑ Langhorne, P., Bernhardt, J., & Kwakkel, G. (2011). Stroke rehabilitation. The Lancet, 377(9778), 1693-1702. http://dx.doi.org/10.1016/s0140-6736(11)60325-5
* ↑ Lexell, J., & Flansbjer, U. B. (2008). Muscle strength training, gait performance and physiotherapy after stroke. Minerva Med, 99(4), 353-68.
* 1 2 Bohannon, R. (2007). Muscle strength and muscle training after stroke. Journal Of Rehabilitation Medicine, 39(1), 14-20. http://dx.doi.org/10.2340/16501977-0018
* ↑ Archives of Physical Medicine and Rehabilitation. (2017). Archives-pmr.org. Retrieved 24 September 2017, from http://www.archives-pmr.org/
* 1 2 Davidson, N. (2017). A systematic review of the Human Activity Profile. - PubMed - NCBI. Ncbi.nlm.nih.gov. Retrieved 7 September 2017, from https://www.ncbi.nlm.nih.gov/pubmed/17264109
* 1 2 Ebrahim, S., Barer, D., & Nouri, F. (1986). Use of the Nottingham Health Profile with patients after a stroke. Journal Of Epidemiology & Community Health, 40(2), 166-169. http://dx.doi.org/10.1136/jech.40.2.166
* ↑ Burr, M., & Phillips, K. (1984). Anthropometric norms in the elderly. British Journal Of Nutrition, 51(02), 165. http://dx.doi.org/10.1079/bjn19840020
* ↑ Johnson, W., Onuma, O., Owolabi, M., & Sachdev, S. (2016). Stroke: a global response is needed. Bulletin Of The World Health Organization, 94(9), 634-634A. http://dx.doi.org/10.2471/blt.16.181636
* ↑ Fuscaldi teixeira-salmela, sylvie n, l. (2001). Effects of muscle strengthening and physical conditioning training on temporal, kinematic and kinetic variables during gait in chronic stroke survivors. Journal of rehabilitation medicine, 33(2), 53-60. Http://dx.doi.org/10.1080/165019701750098867
* ↑ Langhorne, P., Coupar, F., & Pollock, A. (2009). Motor recovery after stroke: a systematic review. The Lancet Neurology, 8(8), 741-754.