# Exercise as it relates to Disease/Walking to Improve Health and Fitness in Stroke Survivors

This page is an analysis of "Effect of Aerobic Exercise (Walking) Training on Functional Status and Health-related Quality of Life in Chronic Stroke Survivors" by Gordon, Wilks & McCaw-Binns in 2013.

## What is the background to this research?

Stroke is a neurological deficit resulting from an acute injury to the brain. It can be classified as ischaemic (loss of blood supply) or haemorrhagic (collection of blood from a burst blood vessel). Stroke is one of the world’s largest health problems and the leading cause of acquired disability in adults.
The aim of this study is to determine if aerobic exercise can improve health related quality of life (QoL) and functional status in stroke survivors (chronic stroke). This study is unique in that explores whether aerobic exercise improves self-reported QoL, rather than just strength and aerobic capacity. QoL is important to measure as it encompasses the patient's perceived health perceptions as well as their correlates e.g. functional status, social support. Previous studies published used gym equipment (treadmills, exercise bikes) and have not explored the use of overground walking - a more accessible and cost-effective treatment.

## Where is the research from?

This study was conducted by the University of the West Indies, Jamaica. The authors are:
* Carron Gordan, Physiotherapist: has published previous papers on physical activity, including ones on older adults.
* Rainford Wilks, Physician: has extensive research experience with a particular focus in the aged population.
* Affette McCaw-Binns, Epidemiologist: has a large experience in research, with over 30 published articles.
The authors have appropriate qualifications and experience in health and research. Though completed in Jamaica, the results can be applied to Australia as the pathology of stroke does not vary country to country, and supervised walking is an accessible treatment tool.
The research was funded by the University of West Indies, and the Caribbean Health Research Council, meaning there were no sponsorships which could have influenced the results.

## What kind of research was this?

The study is a randomised controlled trial (RCT) which involves participants being randomly allocated to a study group;
* Control group: involves either no treatment, usual care or a sham treatment. In this study the control group received therapeutic massage to the affected limbs for 25 minutes, 3 times a week, for 12 weeks. This is an appropriate control as it allows the exercise based intervention to be compared to a passive treatment.
* Intervention group(s): the treatment(s) the researchers want to explore - supervised brisk walking (60%-85% of maximum heart rate) 3 times a week for 12 weeks. Time spent walking was initially 15 minutes and progressed by 5 minutes each week until reaching 30 minutes.
An RCT provides the second best level of evidence – bettered only by a systematic review, which is the analysis of multiple RCTs. An RCT is the best way to determine if there is a relationship between a treatment and an outcome, meaning this method is appropriate to determine whether walking will have positive outcomes for stroke suvivors.
In this study the participants allocation did not remain concealed, and both the participants and physiotherapists knew who was in which group - this can result in potential bias in the results. A strength of the article is that the assessors who took the outcome measures were blinded.

## What did the research involve?
### Participants

Participants were recruited based on the following:
| Inclusion Criteria | Exclusion Criteria |
| ≥40 years old | In rehabilitation or a regular exercise program |
| 6-24 months post stroke | Unstable cardiovascular disease |
| Able to walk | Cognitive deficit |
| Lives in the community | Lives in a nursing home |
The participants in the intervention and control groups were similar on clinical and demographical variables. As the two groups are equal at baseline, the results can be attributed to the treatments, rather than initial differences.

### Outcome Measures

Participants completed questionnaires on their physical health, mental health and activities of daily living. Functional status, aerobic fitness, resting heart rate and lower limb strength were also measured.
The outcome measures used for physical and mental health, functional status, aerobic fitness and lower limb strength have been shown to be valid and reliable in a stroke population. Resting heart rate is appropriate as it is a risk factor for cardiovascular disease.

## What were the basic results?

| Outcome Measure | Intervention (Walking) | Control (Massage) |
| Self-Reported Mental Health | No change | No change |
| Self-Reported Physical Health | Significantly larger improvement compared to the control | No change |
| Functional Status | No change | No change |
| Activities of Daily Living | No change | No change |
| Resting Heart Rate | Significant Improvement | No change |
| Aerobic Fitness | Significant Improvement | No change |
| Lower Limb Strength | No change | No change |
These results are accurate to the data presented in the study. The improvement reported in the self-reported physical health was only seen when comparing it to the control group - there was no significant improvement in the intervention group on its own. Comparatively, the significant improvements gained in resting heart rate and aerobic fitness are attributable to the intervention.

## What conclusions can we take from this research?

The conclusion drawn by the authors, that walking can be used to improve overall health in stroke survivors, is somewhat accurate. It has been found to be effective in improving aerobic fitness and resting heart rate, but only effective in improving self reported physical health when comparing it to massage. It was not effective in improving self-reported mental health, functional status, activities of daily living and lower limb strength. The improvements in aerobic fitness correlate to other studies which used treadmills. This means that regular walking may be as effective as using a treadmill. Since the time this study was published, there are further studies which promote the use of aerobic training in chronic stroke survivors – though none specifically on walking.
There were limitations to the study’s design in regards to blinding, however overall the study is reliable and accurate, meaning the findings can be applied to everyday stroke survivors similar to those in the study.

## Practical advice

* When first starting, walk only 15 minutes, and build up time until 30 minutes is attainable
* Walking in this study was entirely supervised, meaning in the real world a stroke survivor should have someone walking with them to ensure their safety
* Participants were community dwelling and thus these findings should not be applied to stroke survivors who live in nursing homes
* Walking for a total of 90 minutes a week does not meet the recommended physical guidelines. It should be incorporated into a more comprehensive program - see the link to the recommended physical guidelines below

## Further information/resources

* Mobility and Exercise after Stroke: https://strokefoundation.org.au/en/About-Stroke/Help-after-stroke/Stroke-resources-and-fact-sheets/Mobility-and-exercise-after-stroke-fact-sheet
* Exercise for Stroke Survivors: https://enableme.org.au/Resources/Exercise
* Physical Activity and Sedentary Behaviour Guidelines (Australia): http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines

## References

* 1 2 Sacco RL, Kasner SE, Broderick JP, Caplan LR, Culebras A, Elkind MS, et al. An updated definition of stroke for the 21st century. Stroke. 2013;44(7):2064-89.
* ↑ Feigin VL, Krishnamurthi RV, Parmar P, Norrving B, Mensah GA, Bennett DA, et al. Update on the global burden of ischemic and hemorrhagic stroke in 1990-2013: the GBD 2013 study. Neuroepidemiology. 2015;45(3):161-76.
* ↑ Mendis S. Stroke disability and rehabilitation of stroke: World Health Organization perspective. International Journal of stroke. 2013;8(1):3-4.
* ↑ Gordon CD, Wilks R, McCaw-Binns A. Effect of Aerobic Exercise (Walking) Training on Functional Status and Health-related Quality of Life in Chronic Stroke Survivors. Stroke. 2013;44(4):1179-81.
* 1 2 3 Pang MY, Eng JJ, Dawson AS, Gylfadóttir S. The use of aerobic exercise training in improving aerobic capacity in individuals with stroke: a meta-analysis. Clinical Rehabilitation. 2006;20(2):97-111.
* ↑ Pang MY, Eng JJ, Dawson AS, McKay HA, Harris JE. A community‐based fitness and mobility exercise program for older adults with chronic stroke: A randomized, controlled trial. Journal of the American Geriatrics Society. 2005;53(10):1667-74.
* ↑ Centres for Disease Control and Prevention. HRQOL Concepts [Internet]. Cited 2017 September 19. Available from: https://www.cdc.gov/hrqol/concept.htm
* ↑ The University of West Indies. Carron Gordan [Internet]. Mona, Jamaica [cited 2017 August 30]. Available from: http://mona-uwi.academia.edu/CarronGordon
* ↑ The Research Gate. Rainford Wilks [Internet]. [Cited 2017 August 30]. Available from: https://www.researchgate.net/profile/Rainford_Wilks
* ↑ The University of West Indies. Affette McCaw-Binns [Internet]. Mona, Jamaica [cited 2017 August 30]. Available from: http://mona-uwi.academia.edu/AffetteMcCawbinns
* ↑ Pithon MM. Importance of the control group in scientific research. Dental press journal of orthodontics. 2013 Dec;18(6):13-4.
* ↑ Merlin T, Weston A, Tooher R. Extending an evidence hierarchy to include topics other than treatment: revising the Australian'levels of evidence'. BMC medical research methodology. 2009;9(1):34.
* ↑ Sibbald B, Roland M. Understanding controlled trials. Why are randomised controlled trials important? BMJ: British Medical Journal. 1998;316(7126):201.
* 1 2 Viera AJ, Bangdiwala SI. Eliminating bias in randomized controlled trials: importance of allocation concealment and masking. FAMILY MEDICINE-KANSAS CITY-. 2007;39(2):132.
* ↑ Roberts C, Torgerson DJ. Baseline imbalance in randomised controlled trials. BMJ: British Medical Journal. 1999;319(7203):185.
* ↑ Dorman P, Slattery J, Farrell B, Dennis M, Sandercock P. Qualitative comparison of the reliability of health status assessments with the EuroQol and SF-36 questionnaires after stroke. Stroke. 1998;29(1):63-8.
* ↑ Fayazi M, Dehkordi SN, Dadgoo M, Salehi M. Test-retest reliability of Motricity Index strength assessments for lower extremity in post stroke hemiparesis. Medical journal of the Islamic Republic of Iran. 2012;26(1):27.
* ↑ Flansbjer U-B, Holmbäck AM, Downham D, Patten C, Lexell J. Reliability of gait performance tests in men and women with hemiparesis after stroke. Journal of rehabilitation medicine. 2005;37(2):75-82.
* ↑ Loewen SC, Anderson BA. Reliability of the modified motor assessment scale and the Barthel index. Physical Therapy. 1988;68(7):1077-81.
* ↑ Fox K, Borer JS, Camm AJ, Danchin N, Ferrari R, Sendon JLL, et al. Resting heart rate in cardiovascular disease. Journal of the American College of Cardiology. 2007;50(9):823-30.
* ↑ Macko RF, Ivey FM, Forrester LW, Hanley D, Sorkin JD, Katzel LI, et al. Treadmill exercise rehabilitation improves ambulatory function and cardiovascular fitness in patients with chronic stroke. Stroke. 2005;36(10):2206-11.
* ↑ Globas C, Becker C, Cerny J, Lam JM, Lindemann U, Forrester LW, et al. Chronic stroke survivors benefit from high-intensity aerobic treadmill exercise: a randomized control trial. Neurorehabilitation and neural repair. 2012;26(1):85-95.
* ↑ Macko RF, Smith GV, Dobrovolny CL, Sorkin JD, Goldberg AP, Silver KH. Treadmill training improves fitness reserve in chronic stroke patients. Archives of physical medicine and rehabilitation. 2001;82(7):879-84.
* ↑ Severinsen K, Jakobsen JK, Pedersen AR, Overgaard K, Andersen H. Effects of resistance training and aerobic training on ambulation in chronic stroke. American journal of physical medicine & rehabilitation. 2014;93(1):29-42.
* ↑ Billinger SA, Arena R, Bernhardt J, Eng JJ, Franklin BA, Johnson CM, et al. Physical activity and exercise recommendations for stroke survivors. Stroke. 2014;45(8):2532-53.