# Exercise as it relates to Disease/Effectiveness of eccentric strength exercise in individuals after a stroke

This is a critique of the research article: Folkerts MA, Hijmans JM, Elsinghorst AL, Mulderij Y, Murgia A, Dekker R. Effectiveness and feasibility of eccentric and task-oriented strength training in individuals with stroke. NeuroRehabilitation. 2017;40(4):459-71.

## What is the background to this research?

A stroke is a cardiovascular event where the blood supply to the brain is interupted. Individuals can be left paralysed or disabled with 40% having these lifestyle impediments. In 2015 Australia recorded around 36,700 strokes which equates around to 100 incidents a day. This condition has had one of Australia's highest mortality rates with 5.2% of all deaths resultant of a stroke.
This article focusses on how stroke can be caused by lifestyle factors such as obesity, high blood pressure, and physical inactivity whist improving quality of life post-stroke. Lifestyle factors are becoming more prevalent with predictions of more than a million people to have effects of strokes by 2050 especially when 80% of these could be prevented. A successful strength-based program to aid in rehabilitation from a stroke is important to allow a better quality of life. These programs are targeted at improving the range of motion of joints, strength of the muscles to aid in everyday tasks and coordination.

## Where is the research from?

This study was undertaken at the University of Groningen Medical Center, Netherlands and was then published in the international, multidisciplinary journal Neurorehabilitation
This article was Mireille Folkerts first publication as a Ph.D. candidate. She has now published multiple studies in heat stresses on the human body. Juha Hijmans has published multiple studies from 2005 to 2020 on biomechanics and injuries within the body during exercise. The other authors all work at the University of Groningen with each specialising in a different area of exercise and health sciences.

## What kind of research was this?

This research is a crossover randomised controlled trial assessing whether eccentric strength training (EST) or task orientated strength training (TOST) is more beneficial. Each of the eleven participants was observed over 10 weeks and completed both EST and TOST. A randomised controlled study is designed to eliminate bias and less risk of systematic error. This study design is ranked a level II for grades of evidence with level I been the best. This is due to lower subject numbers being present within this study, greater subject numbers would increase significance.

## What did the research involve?

Eleven individuals were selected from the criteria which included:
* Understanding of the Dutch language
* A clinical diagnosis of a stroke
* At least 6 months post-stroke with the ability to make the rehabilitation clinic
* Reduced arm function had been reported by a physician
* Mini-mental state examination for no cognitive impairment
Method
The individuals selected were split into two groups, one group doing EST for the first four weeks and the other group doing TOST. Each group switched over in week six and did the opposite training for the next four weeks. Baseline results were taken before commencement, week five, and week ten. The EST consisted of using lightweight dumbbells and resistance bands going through multiple muscle actions at the shoulder, elbow, and wrist. The TOST had participants use a bilateral upper limb movement based computer game where they held a weighted handlebar for 30 minutes going through different upper body movements. These were completed three times a week, once at the clinic to assess whether progression can be made and twice at home which is self-reported.
Limitations
As apart of the study, individuals had to self-report their participation and results twice a week at home. Potentially subjects could have avoided exercises whilst unsupervised potentially leading to an underestimation of how effective the strength tasks are. Underestimation can also have occurred from the action research arm test (ARAT) where subjects can max out this test which may lead to inaccuracies in their results. Future research incorporating more subjects in their data may allow for a different study design. This can truly show whether task orientated, eccentric strength or a combination of both is more effective.

## What were the basic results?

After ten weeks the researchers found positive trends in strength through the shoulder and elbow. The EST-TOST group had the most significant benefits in muscle function however, no significant differences between the two groups in strength.
| | EST-TOST T0 (mean ± SD) | T2 (mean ± SD) | P | ES | TOST-EST T0 (mean ± SD) | T2 (mean ± SD) | P | ES |
| ARAT Total score | 40.20 ± 9.37 | 53.00 ± 9.91 | 0.043 | -0.90 | 26.00 ± 21.47 | 27.80 ± 21.65 | 0.180 | -0.60 |
| Shoulder Strength HHD Total Score | 83.62 ± 25.98 | 99.96 ± 27.49 | 0.043 | -0.90 | 65.31 ± 20.88 | 96.89 ± 34.43 | 0.042 | -0.91 |
| Elbow HHD Total Score | 104.54 ± 39.87 | 119.15 ± 45.77 | 0.080 | -0.78 | 69.82 ± 38.77 | 110.03 ± 36.14 | 0.043 | -0.90 |
| Wrist HHD Total Score | 46.88 ± 18.71 | 54.13 ± 23.18 | 0.500 | -0.30 | 38.64 ± 13.45 | 47.17 ± 12.84 | 0.068 | -0.82 |
Abbreviations: HHD=Handheld Dynamometer; P=p-value; ES=Effect size; T0=Testing prior to intervention; T2=Final testing.
The researchers reported one participant dropped out of the study due to lack of motivation to continue. Overall strength and upper body mobility was improved in patients post-stroke. This was seen in both sets of groups no matter the sequence of training. The researchers emphasise that task-orientated function has helped to increase the functional ability of the upper limbs when it is preceded by strength training. All other statements made were supported by other studies and statistics stating EST has benefits on the overall strength. One aspect they understand is that further research is required to determine what order works best between EST and TOST preferably with more participants.

## What conclusions can we take from this research?

This study is a useful resource for rehabilitation professionals or physiotherapists who work with stroke patients. It gives an insight in how to return some quality of life back through better movement. The researchers have shown what muscle actions have been successful in strengthing the muscles and improving joint movement. Research supports EST as an effective method of resistance training however, most of these articles are on gait and lower body movements. Further research is required on upper body strength and function in stroke patients.

## Practical advice

For any stroke patient having impaired motor function, seeking out someone specialised in rehabilitation or physiotherapy may improve muscular function through a strength-based program. The program should consist of lightweight dumbbells, resistance bands, or bodyweight exercises to improve coordination. Two sets of five repetitions should be used for heavier loads while three sets of fifteen repetitions are beneficial for lighter loads. These recommendations will encourage strength and muscular endurance benefits as well as neuromuscular control. Performing these under supervision would be recommended for safety. Trying to build-up to the recommended amounts of 150 minutes of physical activity a week can help prevent any extra lifestyle diseases that may occur from the effects of stroke. Trying to exercise as much as possible will help to provide a better quality of life whilst reducing the chance of further strokes.

## Further information/resources

General Stroke Information
Australian Stroke Data
Eccentric Strength Improving Lower Body Mobility
Exercise Tips Post-Stroke
Basic Exercise Ideas Post-Stroke

## References

* 1 2 3 4 5 6 Folkerts MA, Hijmans JM, Elsinghorst AL, Mulderij Y, Murgia A, Dekker R. Effectiveness and feasibility of eccentric and task-oriented strength training in individuals with stroke. NeuroRehabilitation. 2017;40(4):459-71.
* 1 2 3 4 5 Australian Institute of Health and Welfare 2018. Australia’s health 2018. Australia’s health series no. 16. AUS 221. Canberra: AIHW. Available from: https://www.aihw.gov.au/getmedia/56bb591f-6c56-4397-b928-8de6872e2cdd/aihw-aus-221-chapter-3-7.pdf.aspx#:~:text=The%20estimated%20prevalence%20of%20stroke,events%E2%80%94around%20100%20every%20day.
* 1 2 3 4 5 Stroke Foundation 2020, About Stroke; [cited 2020 09/09]; Available from: https://strokefoundation.org.au/About-Stroke
* ↑ O'Donnell MJ, Chin SL, Rangarajan S, Xavier D, Liu L, Zhang H, et al. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. The lancet. 2016;388(10046):761-75.
* ↑ Netherlands: 2020. Mireille Folkerts; [cited 2020 08/09]; Available from: https://www.researchgate.net/profile/Mireille_Folkerts
* ↑ Netherlands: Juha Hijmans; [cited 2020 08/09]; Available from: https://www.researchgate.net/profile/JUha_Hijmans
* 1 2 3 Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plastic and reconstructive surgery. 2011;128(1):305.
* ↑ Lee S-B, Kang K-Y. The effects of isokinetic eccentric resistance exercise for the hip joint on the functional gait of stroke patients. Journal of physical therapy science. 2013;25(9):1177-9.
* ↑ Veldema J, Jansen P. Resistance training in stroke rehabilitation: systematic review and meta-analysis. Clinical Rehabilitation. 2020:0269215520932964.
* ↑ Australian Government. Australia's Physical Activity and Sedentary Behaviour Guidelines and the Australian 24-Hour Movement Guidelines 2019 [cited 14/09/2020]. Available from: https://www1.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-phys-act-guidelines
* ↑ American Heart Association. Exercise Recommendations After Stroke 2014 [cited 14/09/2020]. Available from: https://www.stroke.org/en/professionals/stroke-resource-library/post-stroke-care/patient-focused-rehab-resources/exercise-recommendations-after-stroke