ORIGINAL RESEARCH ARTICLE

Impact of a Stroke Recovery Program Integrating Modified
Cardiac Rehabilitation on All-Cause Mortality, Cardiovascular
Performance and Functional Performance

Downloaded from https://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD33D9/FQ5Fz8lfVGLrVmtPTOI2VIw4234KNX+D4HTdJRaZKsdHS/jWbw== on 11/04/2019

Sara J. Cuccurullo, MD, Talya K. Fleming, MD, William J. Kostis, MD, PhD, Christine Greiss, DO,
Martin S. Gizzi, MD, PhD, Anne Eckert, AuD, MBA, CCC/A, Arlen Razon Ray, PT, Rosann Scarpati, RN,
Nora M. Cosgrove, RN, CCRC, Traymon Beavers, BS, Javier Cabrera, PhD,
Davit Sargsyan, MS, and John B. Kostis, MD, D. Phil
Objective: Using a feasibility analysis and matched subgroup analysis, this study investigated the implementation/safety/outcomes of a stroke
recovery program (SRP) integrating modified cardiac rehabilitation for stroke survivors.
Design: This prospective cohort study of 783 stroke survivors were discharged from an inpatient rehabilitation facility to an outpatient setting; 136
SRP-participants completed a feasibility study and received the SRP including modified cardiac rehabilitation, 473 chose standard of care rehabilitation (nonparticipants), and a group (n = 174) were excluded. The feasibility study assessed the following: safety/mortality/pre-post cardiovascular performance/pre-post function/patient/staff perspective. In addition to the feasibility study, a nonrandomized subgroup analysis
compared SRP-participants (n = 76) to matched pairs of nonparticipants (n = 66, with 10 nonparticipants used more than once) for mortality/pre-post function.
Results: The feasibility study showed the SRP to have the following (a) excellent safety, (b) markedly low 1-yr poststroke mortality from hospital
admission (1.47%) compared with national rate of 31%, (c) improved cardiovascular performance over 36 sessions (103% increase in metabolic equivalent of tasks times minutes), (d) improved function in Activity Measure of Post-Acute Care domains (P < 0.001), (e) positive reviews from SRP-participants/staff. Subgroup analysis showed the SRP to (a) positively impact mortality, nonparticipants had a 9.09 times
higher hazard of mortality (P = 0.039), and (b) improve function in Activity Measure of Post-Acute Care domains (P < 0.001).
Conclusions: Stroke survivors receiving a SRP integrating modified cardiac rehabilitation may potentially benefit from reductions in all-cause
mortality and improvements in cardiovascular performance and function.
Key Words: Cerebrovascular Disorders, Exercise, Mortality, Cardiac Rehabilitation(Am J Phys Med Rehabil 2019;98:953–963)

troke survivors share many risk factors with patients withS
cardiovascular disease. Cardiac rehabilitation (CR) led
to a 45% reduction in 5-yr all-cause mortality rate in individ1,2

uals with cardiovascular disease after percutaneous coronary
intervention.3 Although exercise after stroke improves overall
function,4–7 there is limited evidence demonstrating the impact
of exercise on mortality after stroke.8 There are several studies
that investigate the CR model in patients with transient ischemic attack or minor stroke.9–11 However, there is no study, to
our knowledge, that investigates a modified CR program in patients with stroke that are medically complex and comply with
inpatient rehabilitation facility (IRF) admission criteria.

From the JFK Johnson Rehabilitation Institute, Edison, New Jersey (SJC, TKF, CG,
AE, AR, RS); Cardiovascular Institute at Rutgers Robert Wood Johnson Medical
School, New Brunswick, New Jersey (WJK, NMC, TB, JC, DS, JBK); and Legacy Health System, Portland, Oregon (MSG).
All correspondence should be addressed to: Sara J. Cuccurullo, MD, JFK Johnson
Rehabilitation Institute, 65 James St, Edison, NJ 08818.
This study was supported in part by a Project Grant from the NorthEast
Cerebrovascular Consortium (NECC) awarded to SJC and TKF. NuStep
cross-training bicycles were provided in-kind. The statistical analysis
performed for this study has not been presented in another format.
Financial disclosure statements have been obtained, and no conflicts of interest havebeen reported by the authors or by any individuals in control of the content of
this article.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115
DOI: 10.1097/PHM.0000000000001214

The average unadjusted mortality rate from hospital admission to 1-yr poststroke is 31.1% nationally across Get With
The Guidelines-Stroke hospitals.12 Accordingly, the American
Heart Association/American Stroke Association set a definitive 2020 Impact Goal, to reduce deaths from stroke and othercardiovascular diseases by 20% by 2020.1 Guiding this goal
are benchmarks, also known as Life’s Simple 7.13 However, it
is challenging to improve the Life’s Simple 7 benchmarks in astroke population that has reduced activity levels.
The objectives of this study were to explore the benefits ofan integrated modified CR protocol into an enhanced stroke recovery program (SRP) for stroke survivors in the following
ways: (a) describe the implementation process of a modified
CR protocol into an enhanced SRP, (b) assess feasibility, safety,
and overall outcomes of SRP-participants including all-cause
mortality, cardiovascular performance, and functional performance, and (c) compare a matched subgroup analysis between
SRP-participants and nonparticipants on all-cause mortality
and functional performance.

METHODS
General Design
The feasibility study assessed the following: safety/mortality/
pre-post cardiovascular performance/pre-post function/patient/

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staff perspective (Fig. 1). A prospective feasibility study of the
SRP-participants assessed the implementation of an enhanced
SRP, which includes the following three components: physician
visits, outpatient therapy, and modified CR. The SRP program
evaluated the following outcome measures: safety, mortality,
cardiovascular performance, functional performance, and patient/staff perspective.
In addition to the feasibility study, a nonrandomized subgroup analysis compared SRP-participants (n = 76) withmatched pairs of nonparticipants (n = 66, with 10 nonparticipants used more than once) for mortality and pre-post function.
The nonrandomized subgroup analysis included a cohort of the
SRP-participants from the feasibility study in addition to amatched group of nonparticipants. Subjects were matched on
gender/race/type of stroke and partially on age/baseline functional scores/medical complexity.

Study Population
Subjects
Beginning December 2015 to December 2017, this feasibility
study included patients referred from acute care hospitals admitted
to JFK Johnson Rehabilitation Institute after a stroke/cerebrovascular accident (e.g., ischemic, hemorrhagic, or subarachnoid hemorrhage) and consented to participation in a comprehensive SRP.
The following outlines patient inclusion and exclusion criteria:

FIGURE 1. Stroke recovery program group designation.

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Volume 98, Number 11, November 2019

Inclusion criteria are as follows: 18 yrs or older, be alert
and able to follow simple commands, and provide consent either by the patient/their proxy.
Exclusion criteria are as follows: unable to follow simple
commands and those with reduced alertness.

Ethical Approval
This study was approved by the institutional review boardsof JFK Medical Center and Rutgers Robert Wood Johnson
Medical School. Recruitment and data collection took placeat the JFK Johnson Rehabilitation Institute in New Jersey. Study
participation was voluntary and informed written consent was
obtained by patient/their proxy.

Description of Groups
Group Designation
Of patients admitted to the JFK Johnson Rehabilitation Institute diagnosed with stroke (n = 1014), 214 were deemed ineligible or refused consent (Fig. 1). For the remaining 800
consented subjects, 17 were withdrawn from data collection/analysis for the following reasons: time window was clarified and did
not meet cutoff criteria for days after neurologic event (n = 2),
subjects declined participation in data collection for convenience’s
sake (n = 8), and diagnosis of cerebrovascular accident was erroneous (n = 7). A total of 783 consented subjects were discharged
from the IRF to the outpatient setting at the JFK Johnson Rehabilitation Institute. Once discharged, they were divided andoffered participation in subgroups based on treatment regimen(Fig. 1): SRP-participants, nonparticipants, and other groups.

SRP-Participants
All patients with a diagnosis of stroke, discharged fromthe acute IRF, were offered participation in the outpatient SRP. Patients who agreed to participate in the full SRP (which required all
the following three components: physician visits, outpatient therapy, and modified CR at the JFK Johnson Rehabilitation Institute)were enrolled in the SRP-participant group (n = 136).

Nonparticipants
Patients who opted out of the SRP (did not have any of thethree components: physician visits, outpatient therapy, andmodified CR at the JFK Johnson Rehabilitation Institute) andchose standard of care rehabilitation (physical therapy, occupational therapy, and speech therapy when necessary) not locatedat the JFK Johnson Rehabilitation Institute were placed in the
nonparticipant group (n = 473) and were used for matchingcomparison for subgroup analysis.

Other
A third group, other (n = 174), received only part of the
program (either physician visit or outpatient therapy at the JFKJohnson Rehabilitation Institute but not both). These subjects
were excluded from analysis to avoid variability.

General Description of Overall Program
Subject Recruitment
The JFK Johnson Rehabilitation Institute admitted patients with stroke from multiple acute care hospitals including

Stroke Recovery Program With Modified Cardiac Rehab

three certified comprehensive stroke centers. During their stay,patients/caregivers were educated about the transition of care
into the SRP integrating modified CR, and informed consent
was obtained. Before discharge, the SRP coordinator worked
with the patient and/or family to arrange an outpatient physician
office visit and coordinated homecare services or outpatienttherapy. All patients who were SRP-participants received cardiac clearance, while they were in the inpatient unit, before engaging in the outpatient modified CR.

Enhanced SRP Includes Three Components:
Physician Visits, Outpatient Therapy, andModified Cardiac Rehabilitation
Physician Visits
Physician visits were scheduled at time intervals after
stroke: 30 ± 15, 60 ± 15, 90 ± 15, 120 ± 15 days, for all patientsdischarged from an IRF. At these appointments, risk factor education was provided according to Life’s Simple 713 including
the following: management of blood pressure (BP), cholesterol
control, reduction of blood sugar, getting active, eating better,losing weight, and smoking cessation.

Standard of Care Outpatient Therapies
Traditional physical therapy, occupational therapy, and speechtherapy services were prescribed according to standard of care.

Modified Cardiac Rehabilitation
The modified CR program consisted of group therapy of
4–5 patients with stroke, directed by a specially trained physicaltherapist and physical therapy assistant. A recumbent cross-training bicycle (manufactured by NuStep) provided a low-impact
cardiovascular workout that could be used by subjects of any
functional level. Custom straps and/or leg braces were used
when clinically indicated for the hemiparetic arm and/or leg.
The NuStep machine has an optional seat belt attachment
and arm rests for additional support if needed. In addition, patients with poor sitting balance had more concentrated therapy
supervision during the modified CR group sessions.
After obtaining cardiac clearance, patients were encouraged
to participate in modified CR for 2–3 sessions per week for a
total of 36 sessions. Sessions included a warm-up, interval cardiovascular training, and cooldown for a total of 30 mins withcardiopulmonary parameters monitored. The Borg-Rate ofPerceived Exertion Scale (RPE range 0 = rest and 10 = maximal
effort) was used, maintaining patients in a low to moderatelevel of exertion ( 1–6).14 Patients started at 6 cycles of 4 minsof low-intensity exercise (RPE 1–3), followed by 1 min of restfor 30 mins. By the completion of 36 sessions, patients progressedto 3 cycles of 9 mins of moderate-intensity exercise (RPE 3–6),
followed by 1 min of rest for 30 mins. Before starting the modified CR sessions, a physical therapist performed a baseline assessment of function including baseline cardiovascular function.
This cardiovascular function was assessed in metabolic equivalent of tasks multiplied by minutes (MET-min), to determine
their ability to perform low-intensity exercise (RPE 1–3) for
4 mins, while measuring heart rate, BP, and oxygen saturation.
After therapy evaluation, patients were given a baseline METlevel that they built upon as their modified CR sessions progressed.
Sessions were discontinued for patients who exhibited unstable© 2019 Wolters Kluwer Health, Inc. All rights reserved.

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vital signs or showed clinical signs of cardiac distress and werereferred to their cardiologist.

Differences Between Traditional Cardiac
Rehabilitation and Modified Cardiac Rehabilitation
Comparisons are outlined in Table 1.15–17

Cardiovascular Performance
Progression of cardiovascular aerobic conditioning was measured in MET-min. Individual baseline cardiovascular function
was assessed/measured in MET-min at initial evaluation andthen progressed through every interval cardiovascular training
session for a total of 36 sessions. There was no normative datato compare this group.

Functional Performance

Outcome Measures
General Description/Study Design
The SRP-participants and nonparticipants completed atleast 135 days of follow-up between December 2015 andDecember 2017. A prospective feasibility study of the SRPparticipants assessed the implementation of an enhanced
SRP, which includes the following three components: physician visits, outpatient therapy, and modified CR. The SRP program evaluated the following outcome measures: safety, mortality,
cardiovascular performance, functional performance, and patient/staff perspective. A secondary prospective subgroup analysis was also performed where SRP-participants were matchedwith nonparticipants for comparison of mortality and function.
Subjects were matched on gender/race/type of stroke and partially on age/baseline functional scores/medical complexity.

Feasibility Study Without Matching
SafetySafety in the SRP was assessed by measuring referrals to
cardiology for cardiac symptoms (such as uncontrolled BP,
chest/arm pain/pressure, etc.), measuring the medical reasonsfor early termination of the program, and number of falls during
participation of the modified CR (Fig. 1).

Mortality
Feasibility was assessed comparing SRP-participants withnational normative data. Regarding mortality, SRP-participants
had physician follow-up or phone calls for approximately 1 yr after stroke. Deaths attributed to this study were recorded for up to
365 ± 15 days after stroke.

The Activity Measure of Post-Acute Care (AM-PAC) instrument was designed to measure functional status in adults
across multiple postacute care settings.18 Functional scores wereobtained via the AM-PAC for basic mobility, daily activity, andapplied cognitive domains. The AM-PAC was collected at thefollowing time intervals after stroke: admission to IRF, discharge
from IRF, and 30 ± 15, 60 ± 15, 90 ± 15, and 120 ± 15 days. The
subject’s proxy was used in cases where the subject was unable
to respond (e.g., severe aphasia or cognitive deficits with an Applied
Cognitive AM-PAC score ≤42).18 There are no normative data forpatients recovering from stroke at these specific time intervals.

Patient/Staff Perspective
Testimonials were collected based on individual experiences
during the program.

Subgroup Analysis With Matching
Matching Strategy
This is a nonrandomized study; therefore, patients werematched on gender/race/type of stroke and partially on age/baselinefunctional scores/medical complexity. To optimize the validity ofmatching, a computerized algorithm was used, which maximized
the number of unique nonparticipants (n = 66) matched to SRPparticipants (n = 76). This resulted in 76 pairs of patients, and eachpair included both a nonparticipant and an SRP-participant. For 10of these pairs, the nonparticipants was used twice. This solution
was chosen to avoid eliminating 10 SRP-participants, which would
have reduced the overall sample size for the subanalysis withmatching. Only similar pairs were used for matching; therefore,

TABLE 1. Differences between traditional CR and modified CR
Traditional CR15–17

Modified CR

Equipment
Varied types (e.g., treadmill, arm ergometer, bicycle) NuStep recumbent cross-training bicycle
Cardiac clearance by a cardiologist Yes
YesGroup therapy vs. individual therapy IndividualGroup therapy of 4–5 patients per group
Intensity
Low (to moderate) to highLow to moderate
Progression/time
Risk stratification to determine exercise progression Risk stratification to determine exercise progression
Time
At least 31 mins
At least 30 mins
No. sessions
36
36
Monitoring
Physiologic/telemetry monitoring by CR registered Physiologic monitoring by physical therapists andnurses done at every session
physical therapy assistants done at every session
Items monitored
BP, heart rate, oxygen saturation, blood glucose,BP, heart rate, oxygen saturation, blood glucose,
METs, exercise minutes, modified RPE scale, rate
METs, exercise minutes, modified RPE scale
perceived dyspnea scale
Education/management
BP, lipids, diabetes
BP, lipids, diabetes
Education/counselingTobacco cessation, physical activity, weight loss,
Tobacco cessation, physical activity, weight loss,
psychosocial, nutritional
psychosocial, nutritional (referrals made to rehabilitation
psychologist and nutritionist if needed)956

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Volume 98, Number 11, November 2019

both nonparticipant and SRP-participant groups were comparable at baseline (Fig. 1; Table 2).

Mortality
All-cause mortality rates were compared between the SRPparticipant group and the nonparticipant group up to 365 ±15 days after stroke.

Cardiovascular Performance

Stroke Recovery Program With Modified Cardiac Rehab

SRP-participants were analyzed using Student’s paired t test
to compare difference in function between both groups at
120 ± 15 days after stroke.
This calculation for functional performance used 76
SRP-participants and 66 nonparticipants (with 10 SRP-participants
used twice). Difference in functional outcome improvement from
IRF discharge to 120 ± 15 days after stroke was also analyzed
using Student’s paired t test and mixed-effects linear models.

Medical records from all nonparticipants were reviewed
up to 4 mos after stroke to verify they did not participate inany modified CR. Patients with a recent cardiac event who were
eligible based on medical diagnosis were referred to traditional
CR. Because the nonparticipants did not participate in modified
CR, MET-min were not obtained for this group. MET-min wererecorded for the SRP-participant group.

General

Functional Performance

Feasibility Study Without Matching
Demographics and Other Characteristics of
SRP-Participant Group

Functional assessment of the nonparticipants and SRPparticipants were obtained using the AM-PAC and was collected
at the following time intervals after stroke: admission to IRF, discharge from IRF, and 30 ± 15, 60 ± 15, 90 ± 15, and 120 ± 15 days.

Statistical Methods
Feasibility and Outcomes of SRP-Participant Group
Mortality
Direct comparison of SRP-participants with 1-yr average unadjusted mortality rate from hospital admission to
1-yr poststroke across Get With The Guidelines-Stroke hospitals
was completed.12

Cardiovascular PerformanceStudent’s paired t test was used to compare MET-min atbaseline and after 9, 18, 27, and 36 sessions for all SRP-participants.
An additional analysis was performed to include data for all
sessions at once using a mixed-effects linear model for all
SRP-participants. Patients who attended between 1 and36 outpatient-modified CR sessions within 4 mos after stroke
were included in the analysis.

Functional Performance
Improvement in functional scores for SRP-participants wasanalyzed using Student’s paired t test, comparing IRF admission
with 120 ± 15 days after stroke.

Subgroup Analysis With Matching Comparing
SRP-Participants With Matched Nonparticipants
Mortality
Differences in mortality between SRP-participant group
and nonparticipant group were analyzed by fitting a Cox proportional hazards model adjusted for age. Kaplan-Meier curves
were also generated.

Cardiovascular Performance
Because nonparticipants did not complete any portion of
the modified CR, improvement in MET-min was observed onlyin SRP-participants from baseline to the end of participation.

Functional Performance
Functional outcomes (AM-PAC Basic Mobility, Daily
Activity, and Applied Cognitive) for nonparticipants andAll statistical analyses used R3.5.0 software from the R
Foundation for Statistical Computing.

RESULTS

Table 2 shows the demographics of the participants in the
SRP group (SRPP column).

SafetyIn this cohort, 26 of 136 SRP-participants ended the modified CR early because of medical complications. There werefour referrals to cardiologists because of clinical findings during the cardiovascular training (e.g., uncontrolled BP, chest/arm pain/pressure, etc.). These individuals were treated andtransitioned to traditional CR. Additional reasons for stopping
the program early included the following: orthopedic/arthritis(n = 3), persistent abnormal BP (n = 4), fatigue/cognitive deficits(n = 4), falls outside of the program (n = 3), repeat stroke (n = 1),
seizure (n = 3), and other general medical issues (n = 4). During
the modified CR, there were no recorded falls, injury fromequipment, or overuse injuries reported.

Mortality
One-year poststroke follow-up phone calls revealed that
there were two deaths in the SRP-participant group, yielding
a 1.47% 1-yr unadjusted mortality rate. This is significantly
lower than the average unadjusted mortality rate from hospital
admission to 1-yr poststroke (31.1%) across Get With The
Guidelines-Stroke hospitals.12

Cardiovascular Performance
On average, the SRP-participant group completed 28.09
of 36 sessions of modified CR.
Figure 2 shows the overall average progression of METmin and Figure 2 shows the average percent improvement frombaseline of MET-min over 36 sessions. These figures also include the 95% confidence intervals (CIs) and P values yieldedfrom using Student’s paired t test to compare MET-min at baseline and after 9, 18, 27, and 36 sessions. After 36 sessions, there
was an average difference in MET-min from baseline of 46–95(mean difference [MD] = 47.29, standard error [SE] = 3.40,
95% CI = 40.53 to 54.05, P < 0.001). There was an overall average progression of 103% MET-min over the 36 sessions(mean percent difference = 103.31, SE = 6.77, 95% CI = 89.86
to 116.76, P < 0.001).
A mixed-effects linear model estimated that a patient could
expect a statistically significant improvement of 1.28 MET-min© 2019 Wolters Kluwer Health, Inc. All rights reserved.

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TABLE 2. Descriptive characteristics of the entire cohort and matched-pair group stratified by participation in the SRP
Entire Cohort

Matched Group

Variables

NP (n = 473)

SRPP (n = 136)

P

NP (n = 66)

SRPP (n = 76)P

Age
GenderMale
Hispanic ethnicity
Race
White
Black
Other
Insurance
Medicaid
MedicarePrivate/other
Education level
Type of stroke
Hemorrhagic
Ischemic
Subarachnoid hemorrhage
Left hemiparesis
Right hemiparesis
Bilateral hemiparesis
Balance deficits
Communication/cognitive deficits
Dysphagia
Spasticity
ACH LOSACH NIHSSACH Interventions (tPA/MER)
ARH LOS
Medical complexity
AM-PAC Admission Basic Mobility
AM-PAC Admission Daily Activity
AM-PAC Admission Applied Cognitive
AM-PAC Discharge Basic Mobility
AM-PAC Discharge Daily Activity
AM-PAC Discharge Applied Cognitive
Deceased
Atrial fibrillation
Coronary artery disease/myocardial infarction
Carotid stenosis
Depression
Diabetes mellitus
Substance abuse (drugs/alcohol)
Dyslipidemia
Family history of stroke
Heart failure
Hypertension
Migraine
ObesityPrevious stroke
Previous transient ischemic attack
Peripheral vascular disease
Renal insufficiency
Sleep apnea

71.3 ± 14.6

65.9 ± 15<0.001
NS

69.6 ± 12.4

70.4 ± 11.6

NSNS

245 (52)
48 (10)75 (55)19 (14)33 (50)7 (11)

40 (53)5 (7)266 (56)
115 (24)
92 (19)73 (54)29 (21)34 (25)39 (59)16 (24)11 (17)47 (62)17 (22)
12 (16)

11 (2)
306 (65)
156 (33)
13.1 ± 2.8

7 (5)63 (46)66 (49)13.6 ± 2.9

3 (5)37 (56)26 (39)12.9 ± 2.1

1 (1)40 (53)35 (46)
13.6 ± 2.9

67 (14)392 (83)
14 (3)
208 (44)158 (33)
24 (5)
427 (90)364 (77)207 (44)
15 (3)
9.1 ± 7.9
8.8 ± 7.7
91 (19)17.3 ± 7.8
106.8 ± 2.5
31.1 ± 9.9
30.9 ± 10.1
24.4 ± 20.4
38.4 ± 11.7
37.1 ± 11.7
29.5 ± 18.2
60 (13)125 (26)
138 (29)56 (12)48 (10)218 (46)
26 (5)
252 (53)45 (10)56 (12)410 (87)6 (1)72 (15)121 (26)
32 (7)
16 (3)
63 (13)22 (5)

21 (15)110 (81)5 (4)
51 (38)52 (38)1 (1)120 (88)
94 (69)36 (26)0 (0)6.3 ± 5.5
6.1 ± 6.530 (22)
13.2 ± 6.2
104.7 ± 2
37.6 ± 5.3
36.6 ± 7.1
35.3 ± 14.7
49.9 ± 12.4
46.1 ± 1139.4 ± 14.9
2 (1)
25 (18)26 (19)11 (8)
16 (12)42 (31)10 (7)
57 (42)16 (12)11 (8)109 (80)
4 (3)16 (12)21 (15)6 (4)6 (4)11 (8)
12 (9)4 (6)
61 (92)1 (2)30 (45)24 (36)0 (0)62 (94)48 (73)21 (32)3 (5)8.7 ± 7.7
7 ± 7.8
14 (21)15 ± 9.7
105.4 ± 2
37.2 ± 5.6
35.4 ± 7.6
33.6 ± 15.2
43.9 ± 10.3
41.8 ± 9.9
36.8 ± 11.7
10 (15)14 (21)
13 (20)7 (11)5 (8)
29 (44)2 (3)35 (53)6 (9)7 (11)
59 (89)0 (0)11 (17)21 (32)5 (8)3 (5)9 (14)3 (5)4 (5)71 (93)1 (1)32 (42)31 (41)0 (0)67 (88)55 (72)27 (36)0 (0)5.4 ± 46.9 ± 7.7
20 (26)14 ± 5.4
105 ± 236.8 ± 5.2
36.2 ± 6.6
33.6 ± 13.7
45.8 ± 9.4
43.5 ± 9.9
37.9 ± 12.3
1 (1)
15 (20)19 (25)9 (12)
11 (14)22 (29)7 (9)33 (43)9 (12)6 (8)
66 (87)1 (1)9 (12)
16 (21)
5 (7)
5 (7)
6 (8)
8 (11)

NS
NS<0.001

NS
NS

NS
NS
0.045
NS
NS
<0.001NS<0.0010.001
NS<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001
NS
0.026
NS
NS
0.002
NS
0.025
NS
NS
NS
NS
NS
0.019
NS
NS
NS
NS

NS
NS

NS

NS
NS

NS
NS
NA
NS
NS
NS
NS
0.002
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
0.006
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS

(Continued on next page)958

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Stroke Recovery Program With Modified Cardiac Rehab

TABLE 2. (Continued)
Entire Cohort

Matched Group

Variables

NP (n = 473)

SRPP (n = 136)

P

NP (n = 66)

SRPP (n = 76)

P

SmokerBody mass index
Systolic BP
Diastolic BP
Low density lipoprotein
Hemoglobin A1c

114 (24)
27.8 ± 6.1
141.6 ± 21.975 ± 11.4
89.5 ± 36.3
6.6 ± 1.9

45 (33)29.1 ± 6.5
144.4 ± 21.2
75.9 ± 10.7
93.1 ± 39.8
6.5 ± 2

0.046
0.042
NS
NS
NS
NS

12 (18)27.4 ± 5.6
144.1 ± 21.7
77.9 ± 11.7
89.6 ± 33.8
6.9 ± 2.5

34 (45)28.1 ± 6.6
146.6 ± 21.5
74.9 ± 1089.5 ± 39.2
6.2 ± 1.7

0.001
NS
NS
NS
NS
NS

Bold variables were used for matching. Values are n (%) for categorical variables and mean ± SD when appropriate.
ACH, acute care hospital; ARH, acute rehabilitation hospital; LOS, length of stay (days); MER, mechanical endovascular reperfusion; NA, significance test notapplicable; NP, nonparticipant; NS, not significant at the α = 0.05 significance level; SRPP, stroke recovery program-participant; tPA, tissue plasminogen activator.

from baseline for every additional session they completed (estimate = 1.28, SE = 0.07, 95% CI = 1.14 to 1.42, P < 0.001).
This model further demonstrated that a patient could expect astatistically significant improvement of 8.74 MET-min for every unit increase in the average number of sessions per week
they completed (estimate = 8.74, SE = 2.81, 95% CI = 3.18
to 14.30, P = 0.002).

Functional Performance
Functional scores in SRP-participants were obtained using
the AM-PAC measured at each time point including the following: IRF admission, IRF discharge, 30 ± 15, 60 ± 15, 90 ± 15,
and 120 ± 15 days after stroke (Fig. 3).
For the Basic Mobility score, the average admission score
for SRP-participants was 38, suggesting limited indoor mobility
requiring assistance. By day 120, the average score for SRPparticipants was 64, indicating independent indoor mobility
and emerging comfort with community-level mobility. This
showed an average improvement of the SRP-participant Basic

Mobility score of 26 points (MD = 26.41, SE = 0.94, 95% CI =24.54 to 28.28, P < 0.001), which is much greater than theminimally detectable change of 4, representing the amount ofchange needed to exceed measurement variation.19
For the Daily Activity score, the average admission score
for SRP-participants was 37, indicating that daily tasks will require assistance for completion. By day 120, the average score
for SRP-participants was 63, suggesting an easier ability to perform self-care tasks, although housekeeping and laundry may stillrequire assistance. This showed an average improvement of the
SRP-participant Daily Activity score of 26 points (MD = 26.40,
SE = 1.60, 95% CI = 23.24 to 29.56, P < 0.001), which ismuch greater than the minimally detectable change of 4.19
For the Applied Cognitive score, the average admission
score for SRP-participants was 35, suggesting difficulty withcognitive processing and communication. By day 120, the average score for SRP-participants was 51, indicating the ability tocomplete complex tasks and communication without difficulty.
This showed an average improvement of the SRP-participant

FIGURE 2. A and B, MET-min progression over number of sessions for SRP-participants.
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FIGURE 3. Average AM-PAC score by follow-up time point for SRP-participants.

Applied Cognitive score of 16 points (MD = 15.90, SE = 1.32,
95% CI = 13.28 to 18.53, P < 0.001), which is much greater thanthe minimally detectable change of 7.19

characteristics with the exception of acute care hospital lengthof stay and smoking status (Table 2).

Mortality
Patient/Staff Perspective
Table 3 summarizes comments.

Subgroup Analysis Comparing SRP-ParticipantsWith Matched Nonparticipants
The 142 patients in the matched cohort consisted of nonparticipants (n = 66) and SRP-participants (n = 76). After matching
between nonparticipants and SRP-participants, no clinical difference was noted in demographic, clinical, and/or functional

During a median follow-up of 85 days (1 day to approximately 1 yr), there were 2 deaths (1%) in the SRP-participantgroup (of 136 SRP-participants), compared with 60 deaths(13%) in the nonparticipant group (of 473 nonparticipants).
After matching, 1 death (1.3%) was reported in the SRP-participantgroup (of 76 SRP-participants) compared with 10 deaths(15.2%) in the nonparticipant group (of 66 nonparticipants).
This shows a difference in mortality of 13.9%. Kaplan-Meiercurves for each of the groups in the matched cohort are shownin Figure 4. After fitting a Cox proportional hazards model, a

TABLE 3. Patient/staff perspective of the SRP
Individual

Comment“I was very depressed. I was sitting home and started worrying about my family and kids. I wasn’t able to talk, walkor move my arms or legs. I would recommend the SRP to everybody. The SRP helped me get back to normal.”Patient #2“There is life after stroke. I feel that I have a second chance. With the help of the doctors and therapists in the SRP,
I’ve learned a lot about what I need to do to stay healthy.”
Patient #3“I would recommend the SRP to anybody who had a stroke. If I had stayed home, I never would have gotten this far
in my recovery.”Patient #4“I really think the SRP is an important program but I am on a fixed income. The biggest problem that I had was paying
the copayments for my therapy sessions, but I’m glad I did it.”Patient #5“It took commitment for me to complete all 36 cardiac rehab sessions, but it was worth it.”
Staff #1 (physical therapist) “Patients are really motivated to participate in the cardiovascular conditioning program, not only for endurance, butalso for socialization. It gives them positive energy towards their recovery. As a therapist, I have seen that the additionof the modified CR program has enhanced patient performance allowing for more functional gains.”
Staff #2 (speech therapist) “The program has fostered a multidisciplinary approach. This has impacted the quality of life and outcomes of patients
after a stroke in a positive direction.”
Staff #3 (research staff )“Although we had interest from many of our patients to participate in the SRP, there were patients who expressed concerns
as to why they did not want to participate (e.g., transportation issues, financial limitations for therapy copayments,
relocation, scheduling conflicts, lack of interest in the program, lack of family support, decreased motivation andinability to commit to the therapy schedule).”Patient #1

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Stroke Recovery Program With Modified Cardiac Rehab

FIGURE 4. Survival curves for all-cause mortality in SRP-participants and nonparticipants.

hazard ratio of 0.11 (SE = 1.07, 95% CI = 0.01 to 0.90,
P = 0.039) was obtained for the effect of participant group, adjusted for the effect of age (Fig. 4). The results of this model
suggest that nonparticipants have a 9.09 times higher hazardof mortality. The corresponding CI and P value of 0.039 suggestthat this result is statistically significant.

Cardiovascular Performance
Only SRP-participants enrolled in modified CR, and thus,
there is no matched group to compare with this group.

Functional Performance
Comparing functional improvement at day 120 ± 15 days
between SRP-participants and nonparticipants using Student’s
paired t test. Figure 5 compares functional scores using the
AM-PAC between nonparticipants and SRP-participants from
IRF admission to 120 ± 15 days after stroke.
For the Basic Mobility score, the average admission score
for nonparticipants was 37, compared with the average admission score for SRP-participants of 37, which is not clinicallysignificant. By day 120, the average score for nonparticipants
was 55, compared with the average score for SRP-participantsof 62, with a difference of 7 points (MD = 8.04, SE = 1.73,
95% CI = 4.55 to 11.52, P < 0.001), showing clinicalsignificance.19
For the Daily Activity score, the average admission score
for nonparticipants was 35, compared with the average admission score for SRP-participants of 36, which is not clinicallysignificant. By day 120, the average score for nonparticipants
was 52, compared with the average score for SRP-participantsof 59, with a difference of 7 points (MD = 8.14, SE = 2.61, 95%
CI = 2.86 to 13.42, P < 0.001), which has clinical significance.19
For the Applied Cognitive score, the average admission
score for nonparticipants was 34 compared with the average admission score for SRP-participants of 34, which is not clinicallysignificant. By day 120, the average score for nonparticipants
was 44, compared with the average score for SRP-participantsof 49, with a difference of 5 points (MD = 4.58, SE = 2.32,

95% CI = −0.11 to 9.27, P = 0.056), showing partial clinicalsignificance.19
Comparing functional improvement from IRF discharge
to day 120 ± 15 days between SRP-participants to nonparticipants using mixed-effects linear model (Figs. 5A–C). The CIs
and P values correspond to the results yielded after using amixed-effect linear model. The estimates for participant groupeffect adjusted for the effect of age for Basic Mobility (estimate = 8.46, SE = 1.18, 95% CI = 6.12 to 10.80, P < 0.001),
Daily Activity (estimate = 7.67, SE = 1.61, 95% CI = 4.47 to10.88, P < 0.001), and Applied Cognitive scores (estimate = 6.69,
SE = 1.53, 95% CI = 3.65 to 9.74, P < 0.001) were all positiveand statistically significant. The results of this model suggestthat a patient in the SRP-participant group can expect to havegreater improvement over time than a patient in the nonparticipant group in all AM-PAC score domains.

DISCUSSION
Using a feasibility analysis and matched subgroup analysis,
this study investigated the implementation, safety, and outcomesof a SRP integrating modified CR for stroke survivors. The results of this feasibility analysis demonstrate that implementationof an enhanced SRP was safe and beneficial for improvements
in cardiac and functional performance and showed a markedly
low mortality. The patient/staff perspective overall was vastly
positive. Matched subgroup comparison showed that implementation of a specialized outpatient SRP with modified CR led to astatistically significant reduction of all-cause mortality, as wellas improvement of cardiovascular capacity and overall function.
This study is unique because it uses a modified CR protocol and physiatrist monitoring as part of an enhanced SRP.
The SRP uses an innovative approach to help patients with stroke
achieve the American Heart Association/American Stroke
Association’s Life’s Simple 7.13 To our knowledge, there are no similar comparison studies. Just as traditional CR has been implemented at a national level for patients with cardiac disease
that comply with appropriate diagnostic criteria, the SRP© 2019 Wolters Kluwer Health, Inc. All rights reserved.

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FIGURE 5. A, B, and C, Comparison of AM-PAC scores for SRP-participants to nonparticipants up to 120 days.

with modified CR shows promise to be implemented nationally in outpatient settings for patients recovering from stroke.
Because of the comprehensive nature of the SRP, it is challenging to isolate which elements of SRP are responsible forthese outcomes including the following: increased care time,increased physical activity, improved exercise capacity, improved medication adherence, increased motivation, and overall
surveillance poststroke. Potential benefits of regular exercise inpatients with stroke include improved functional capacity andreduced risk of additional cardiovascular events.20 Benefits ofregular exercise in the general population include the following: increased exercise tolerance, decreased BP, and increased
insulin sensitivity.21 Psychosocial benefits also include improved
health-related quality of life.6
This data set focuses on patients discharged from an acute
IRF who start an outpatient rehabilitation program within 30 ±15 days after stroke. As such, it does not include patientsdischarged from an acute care hospital directly to home, askilled nursing facility, or a long-term care facility. The referral of patients to an IRF was included in recent guidelines forstroke rehabilitation.22
With respect to formal recommendations from the American
Heart Association/American Stroke Association, it is well documented that physical activity and exercise prescription should
be incorporated into the management of stroke survivors, witha focus on low- to moderate-intensity aerobic activity, musclestrengthening activity, reduction of sedentary behavior, andrisk management for secondary prevention of stroke.20 The SRP
accomplishes these tasks with direct medical supervision combined with formal therapy and interval cardiovascular training.
Although other programs include general exercise as acomponent of stroke rehabilitation, this feasibility study isthe first to use a medically supervised, interval cardiovasculartraining program within an enhanced SRP that is safe and efficacious. The SRP has been proven to be safe because of962

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surveillance by a physiatrist, medication monitoring, cardiovascular clearance, and support by cardiologists and neurologists.
The modified CR was well tolerated. Cardiologists were engaged when cardiac symptomatology presented. The importanceof a safe program is paramount, because of the comorbid medical
conditions that many patients recovering from stroke have. Traditional CR has been proven to be safe in various studies.23–25
The feasibility analysis without matching showed progression of total MET-min and percent increase of MET-min, whichsuggests improvement in exercise capacity through the SRP.
Improvement in exercise capacity was detected as few as 9 sessions and continued throughout the 36 sessions. The results indicate that the improvement was statistically significant forevery number of sessions. This trend is apparent in traditional
CR literature,26,27 but there is limited evidence documenting
this phenomenon in patients with stroke.4–7 Improvements inexercise capacity may have had the secondary benefit of augmenting improvements in mortality and function. All-cause
mortality rate (1.47%) for the SRP-participants was significantly lower than the average unadjusted mortality rate from
hospital admission to 1-yr poststroke (31.1%) across Get With
The Guidelines-Stroke hospitals.12 The AM-PAC has beenvalidated in postacute care patients with major neurological,
orthopedic, and major medical conditions.18 A functional
evaluation was completed using AM-PAC scores showing astatistically significant improvement in functional scores inall three AM-PAC domains (P < 0.001).
Subgroup analysis showed a statistically significant difference in mortality between nonparticipants and SRP-participants.
The SRP-participants showed nine times reduced risk of death
compared with the nonparticipants. In comparison with the traditional CR literature, a reduction in mortality was also seen byvarious studies.3,26 After matching, 1 death (1.3%) was reported
in the SRP-participant group compared with 10 deaths (15.2%)
in the nonparticipant group.
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Volume 98, Number 11, November 2019

A more detailed evaluation of function was completed using
the AM-PAC scores across all three domains. The AM-PAC has
been found to be reliable and valid in patients with stroke.18
The SRP-participants showed a clinical and statistically significant improvement in functional scores in all three AM-PAC
domains (P < 0.001).19 As expected, nonparticipants and
SRP-participants showed similar IRF admission and discharge
AM-PAC score changes. The SRP intervention diverges after
acute IRF discharge, with the 30-day time point as the firsttime point showing a difference between the groups.
Because of the comprehensive nature of the SRP, when executing a subgroup analysis comparing SRP-participants withmatched nonparticipants, it is acknowledged that there was additional care time afforded to the SRP-participants that the nonparticipants did not receive with the standard of care. Because alimitation of nonparticipant self-reporting of care time was inconsistent and problematic to record, it is not possible to exclude
the possibility that the better outcomes in the SRP-participants
may be in part due to additional care time.
Another limitation of this nonrandomized study is its observational nature. Patients were matched as described previously.
However, the experimental design did not allow randomizationof the treatment and this may be a source of selection bias. Additional data collection will increase the statistical power in future analyses of this ongoing study. However, this study has
significant strengths, including the longitudinal follow-up,
the completeness of data collection, the multidisciplinary comprehensive nature of the program, and determination of improvements after implementation of the program.
The data demonstrate that a comprehensive SRP integrating modified CR provides clinically and significant reduction in
mortality, in addition to a functional improvement across three
separate outcome tests designed to measure function throughout
the postacute care continuum. For the subgroup analysis, thesample size of SRP-participants (n = 76) and nonparticipants(n = 66) after matching was used for this initial ongoing study.
This study provides additional support for structured exercise
training poststroke as a standard of postacute care. This study
also provides a foundation for supporting clinical practice guidelines for many stroke survivors who currently have limited resources for postacute stroke care and rehabilitation.

CONCLUSIONSThe study showed that the SRP integrating modified CR
was safe, well received, and showed an increase in cardiovascular and functional performance as well as a decrease in all-cause
mortality. Similar to the documented benefits of traditional CR,
stroke survivors benefit from coordinated access to physicalmedicine and rehabilitation physicians, cardiologists, and neurologists throughout the postacute care continuum. Continued
research in this area is necessary to support healthcare policychange to benefit stroke survivors.
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