# Exercise as it relates to Disease/Effective exercise rehabilitation for stroke patients; aerobic vs resistance training
## Background
### Prevalence

Stroke is the fifth most common cause of death worldwide. An estimated 350 000 Australians are currently recovering from stroke, with approximately 150 000 living with a stroke-related disability.

### What is a Stroke?

A stroke occurs when there is a sustaining disruption of blood flow within the brain. Depending on where the disruption occurs, the death of specialized cells will cause severe disabilities in mental cognition, motor control, or speech
* Ischemic Stroke - A blood clot from a distant blood vessel breaks off, travels to the brain and blocks a small blood vessel (embolic). Alternatively, the blood vessel becomes so narrow that blood cannot pass through it (caused by atherosclerosis)(thrombotic)
* Haemorrhagic Stroke – A blood vessel in the brain bursts (caused by thinning of vessel lining) (Intracerebral). Otherwise, bleeding occurs in the area surrounding the brain (not in the brain tissue)(subarachnoid)

### Causes of Stroke

* Abnormal blood cholesterol and lipoprotein levels
* Hypertension and atherosclerotic lesions within blood vessels
* Diabetes, high inflammatory responses, carotid artery disease and other chronic cardiovascular diseases
These comorbidities significantly increase the chances of a stroke, and stem from risk factors such as,:
| Preventable Factors | Non-Preventable Factors |
| * Obesity and physical inactivity * Poor diet (high in fat) * Alcohol consumption and Smoking. | * Age * Race and gender * Family History |

## Effects of Stroke

* Paralysis of a limb or entire side of the body
* Dysphagia, (difficulty swallowing)
* Ataxia (Damage to the cerebellum, affecting coordination and gait)
* Aphasia (Expressive and receptive - difficulty communicating and understanding words)
* Chronic pain and sensory dysfunction
* Loss of cognitive function (memory, learning, higher order thinking)

## Current Rehabilitation Methods

* Modification of lifestyle (e.g. quit smoking, regular exercise, balanced diet)
* Appropriate pharmacological therapy to manage comorbidities and pain
* Exercise regimes to improve strength and physical endurance

## Exercise As An Ongoing Recovery Intervention: Aerobic Exercise vs. Resistance Training

| Aerobic Exercise | Resistance Exercise |
| Improves: * Cardiovascular fitness and aerobic capacity (peak O$_2$) * Musculoskeletal function * Rate of fatigue/improved endurance * Sensorimotor function and cognitive activity * General health (weight loss, lipoprotein levels, inflammation, glucose regulation, blood pressure) Impact on Quality of Life: * Perform daily activites without immense fatigue * Reduces/prevents comorbidites * Reduces depression and psychological issues Main Goal: To reduce fatigue levels | Improves: * Muscle strength * Motor performance and coordination * Gait * Balance (static and dynamic) Impact on Quality of Life: * Improves patient's self-sufficiency in performing daily activities * Reduces activity limitations - allows patient to socialize and participate in various activities Main Goal: To improve musculoskeletal strength and coordination Note: Prolonged duration (i.e. greater than 6 months) of an effective exercise program is related to an improved functional outcome, and a reduced risk for further cardiovascular problems. |

## Recommendations for Effective Exercise Rehabilitation

| Exercise | Recommended Activity from The American Heart Association and the National Heart Foundation of Australia, |
| Aerobic | 30 mins of moderate intensity (walking, riding), on most days of the week |
| Resistance | Low to moderate intensity 2–3 days a week targeting weakened muscles |
Before undertaking exercise, the patient must be prescreened. Current medication, range of mobility, strength and associated comorbidities must be considered in devising a supervised exercise program.

## Improving Compliance

* Involvement and support from the patients family and social interaction
* Psychological state (a positive outlook) and an interest in prescribed exercises will lead to increased motivation
* Altering activities to reduce exercise-related pain caused from comorbidities
* Catering to patient’s daily schedule (associated time restraints)

## Further reading

* American Heart Association recommendations and Australian physical activity recommendations
* Stroke Foundation factsheet and Stroke Foundation website Video: Common rehabilitation exercises

## References

* 1 2 3 Weerd, L. et al. (2012) ‘Health care in patients 1 year post-stroke in general practice: research on the utilization of the Dutch Transmural Protocol transient ischemic attack/cerebrovascular accident’. Australian Journal of Primary Health. Vol. 18 pp. 42 - 49
* 1 2 3 4 World Health Organization (2005). WHO STEPS Stroke Manual: The WHO STEPwise approach to stroke surveillance. Geneva, World Health Organization.
* 1 2 3 4 5 6 7 Gordon, N. et al. (2004) ‘Physical Activity and Exercise Recommendations for Stroke Survivors: An American Heart Association Scientific Statement’ Journal of the American Heart Association. Vol. 109. pp 2031 – 2040
* 1 2 Perloff, J., Marelli, A. & Miner, P. (1993). ‘Risk of stroke in adults with cyanotic congenital heart disease’ Journal of American Heart Association. Vol. 87 pp. 1954-1959
* ↑ Widar M, Samuelsson L, Karisson-Tivenius S & Ahlstro G, 2002, ‘Long-term pain conditions after a stroke’, Journal of Rehabilitation Medicine, Vol. 34, pp. 165–170
* 1 2 Luft A, et al. (2008),’Treadmill Exercise Activates Subcortical Neural Networks and Improves Walking After Stroke A Randomized Controlled Trial’, Journal of the American Heart Association, Vol. 39, pp. 3341-3350
* ↑ Patterson, S., Ross-Edwards, B., & Gill, H. (2010) ‘Stroke maintenance exercise group: pilot study on daily functioning in long-term stroke survivors’. Australian Journal of Primary Health. Vol. 16 pp. 93 -97
* ↑ Rimmer J. et al. (2009), ‘A Preliminary Study to Examine the Effects of Aerobic and Therapeutic (Nonaerobic) Exercise on Cardiorespiratory Fitness and Coronary Risk Reduction in Stroke Survivors’, Archives of Physical Medicine and Rehabilitation, Vol. 90, No. 3, pp.407-412
* ↑ Ada, L., Dorsch, S. & Canning, C. (2006) ‘Strengthening interventions increase strength and improve activity after stroke: a systemic review’. Australian Journal of Physiotherapy. Vol. 52 pp. 241 -248
* ↑ Flansbjer,U, Lexell, J. & Brogardh, C. (2012) ‘Long-term benefits of pregressive resistance training in chronic stroke: a 4-year follow up’. Journal of Rehabilitation Medicine. Vol. 44 pp. 218 - 221
* ↑ Briffa, T. et al. (2006) National Heart Foundation of Australia physical activity reccomendations for people with cardiovascular disease. Sydney. National Heart Foundation of Australia