REVIEW
Physical ﬁtness in persons with hemiparetic stroke
Meigen Liu, Tetsuya Tsuji,1 Kimitaka Hase, Yukihiro Hara2 and Toshiyuki Fujiwara
Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo
1Department of Rehabilitation Medicine, Shizuoka Cancer Center Hospital and Research Institute, Shizuoka
2Department of Rehabilitation Medicine, Nippon Medical School, Tokyo, Japan(Received for publication on May 13, 2003)

Abstract. In persons with hemiparetic stroke, assessment and promotion of ﬁtness have so far
received limited attention, partly because of the lack of appropriate measures applicable to them. Because these mobility-impaired persons are prone to inactivity, disuse and insulin resistance are likely tooccur, and can aggravate the already signiﬁcant health and economic consequences that stroke entails.
It is therefore important to assess objectively their ﬁtness to devize effective and efﬁcient ﬁtness promotion programs. Because of physical limitations, however, many persons with stroke cannot perform
traditional stress testing using a treadmill or a cycle ergometer, and maximal oxygen consumption,
which is regarded as a gold standard, is not a practical measure. In this article, we reviewed the current
status of research on ﬁtness in persons with hemiparetic stroke from the perspectives of evaluation,
structure analysis of ﬁtness, and longitudinal changes during a rehabilitation program. As a measure ofﬁtness, indices obtainable with a submaximal exercise are proposed, such as anaerobic threshold andheart rate oxygen coefﬁcient. Protocols applicable to persons with hemiparetic stroke with a variety offunctional limitations have been developed (basic bedside activities, bridging activity, or single arm
ergometry). The structure of their ﬁtness is demonstrated to be described by a ﬁtness model of healthy
persons (cardiopulmonary, muscular and metabolic dimensions) if the paresis/activities of daily living
dimension is added. Several studies suggest that ﬁtness improves during a conventional stroke rehabilitation program. Studying the changes of the above four dimensions can help develop more effectiveﬁtness training programs. (Keio J Med 52 (4): 211–219, December 2003)
Key words: cerebrovascular disease, immobilization syndrome, stress testing, oxygen consumption,
rehabilitation

Introduction
As in other developed countries, stroke poses us
important health and economic problems in Japan.1
The annual medical expenditure generated by stroke
was estimated at approximately ¥1,920 billion ($17.46
billion) in 1997, or about 6.6% of the total medical
expenses. The number of persons left with stroke residuals was estimated as 1.7 million in 1996, and stroke ispresumed to have caused about 30 to 40% of the bedridden population. It is the most frequent cause of
disability, accounting for 12.2% of all causes in 1996
followed by bone and joint disease (12.1%) and heartdisease (10.0%), and the most frequent reason for rehabilitation referrals.

In the rehabilitative management of persons withstroke, efforts have been made to predict their functional outcomes as early as possible after the onset
using standardized functional instruments,2,3 and to
maximize their functional recovery and independence
utilizing limited health care resources efﬁciently. However, compared with approaches to motor and cognitive
impairments and limitations in activities of daily living(ADL), assessment and promotion of the ﬁtness ofstroke patients have so far received limited attention,
partly because of the lack of appropriate measures ofﬁtness applicable to this population. Because thesemobility-impaired individuals are prone to inactivity intheir daily lives, disuse-related changes of variousorgans and systems such as cardiovascular, bone-joint,

Reprint requests to: Dr. Meigen Liu, Department of Rehabilitation Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjyuku, Tokyo, 160-8582, Japan, telephone: þ81-3-5362-3833, facsimile: þ81-3-3225-6014, e-mail: QZV11742@nifty.ne.jp
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Liu M, et al: Fitness in stroke

muscular and metabolic systems, are likely to occur.
This can hinder successful rehabilitation,4 and can interfere with their reintegration into the community after
medical rehabilitation.
Furthermore, these patients are also at higher risk ofdeveloping metabolic disorders such as adverse changes
in body composition, glucose intolerance and/or hyperinsulinemia.5,6 Recent studies strongly suggest that
insulin resistance related to an inactive life style is amajor risk factor of atherosclerotic diseases,7,8 and thiscan have important implications for persons with stroke
for whom secondary prevention of stroke recurrence
as well as primary prevention of cardiac events should
be given a high priority.
Therefore, disuse and insulin resistance brought
about by inactivity can aggravate the already signiﬁcanthealth and economic consequences that stroke entails,
and it is important to assess objectively the physicalﬁtness of patients with stroke to devise effective and
efﬁcient ﬁtness promotion programs. In this article, wewill review the current status of research on ﬁtness inpersons with stroke from the following perspectives:
1) how can we evaluate their ﬁtness?; 2) what is the
structure of their ﬁtness?; and 3) what are the effects ofrehabilitation programs on their ﬁtness?
How Can We Evaluate Their Fitness?
Because of physical the limitations, many patientswith stroke cannot perform the traditional stress testing
using a conventional treadmill or a cycle ergometer
exercise that are commonly practiced in healthy persons. Therefore, the ﬁrst obstacle we are faced with is
how we should evaluate their ﬁtness. What are the appropriate and practical modes of stressing them? What
indices of ﬁtness can we employ for those who cannot
perform maximal exercise? We will ﬁrst discuss indicesof ﬁtness that can be used in patients with hemiparetic
stroke, and then review modes of stressing them andintroduce our experience of evaluating their ﬁtness
using basic bedside activities, bridging activity, andsingle arm ergometry.
The indices of ﬁtness
Oxygen consumption (V̇O2 ) increases linearly with
the increase in workload up to a certain point, and thisis called maximal oxygen consumption (V̇O2 max).9V̇O2 max indicates the maximum possible energy output
produced by aerobic metabolism in a unit time, and it isregarded as a gold standard index of ﬁtness. When V̇O2
measurement with a sophisticated equipment is difﬁcult,the observed maximal heart rate (HRmax) can be used
as a simple measure of aerobic capacity, because HR
correlates well with V̇O2 .9 When performing maximum
stress testing is impossible, V̇O2 is estimated by extrap-

olating the HR to the age-predicted HRmax to read theV̇O2 level corresponding to the predicted HRmax.
In persons with motor disability and older individuals, maximal or near maximal loading is usually difﬁcult
or impossible to achieve, and in general, V̇O2 max is
not a practical index of ﬁtness. Even the extrapolation
method requires a relatively high workload. In thiscontext, indices obtainable with submaximal exercises
have been proposed as measures of ﬁtness, such as theanaerobic threshold10 and the HR oxygen coefﬁcient(HR-O2 -coeff).11–14
Anaerobic threshold (AT): The AT is deﬁned as thepoint where anaerobic metabolism becomes dominant
and blood lactate begins to rise during a graded exercise.10 It is obtained by measuring blood lactate levels(lactate threshold; LT). Alternatively, the ventilatory
threshold (VT), or a point where a greater increasein ventilation is observed in comparison with the increase in V̇O2 , is often used in clinical practice. The
point where blood lactate equals 4 mmol/l is called theonset of blood lactate accumulation (OBLA), and thisindicates that energy is produced predominantly by anaerobic metabolism. The AT usually corresponds to 55
to 65% of V̇O2 max.
There are several studies measuring the AT in persons with stroke using a graded cycle ergometer,15
treadmill,16 or stand-up exercise,17 and the AT is suggested as a useful index of aerobic capacity obtainablewith submaximal exercises. However, we still need tostress the patients to a relatively high workload level tomeasure AT, and this limits its application to those whoare at least functional ambulators. Also, questions areraised as to their physiological signiﬁcance, method ofdetermination, reproducibility, and the relationship between the LT and VT.18,19
HR-O2 -coeff: The HR-O2 -coeff is deﬁned as theregression coefﬁcient between V̇O2 and HR.11 It isequivalent to the oxygen pulse (V̇O2 /HR) when the HR
is extrapolated to inﬁnity, and signiﬁes the oxygen supply capacity of the cardiopulmonary system. It is obtainable with submaximal exercise, and is therefore a
useful measure of ﬁtness in persons with disability
who cannot perform maximal exercise. This index isreported to correlate well with activity levels11 or ambulatory levels13 in persons with hemiparetic stroke,
and with measured V̇O2 max in healthy persons.11
Modes of stress testing
As for the modes of stress testing, investigators
have tried various forms of modiﬁed stress testing suchas single arm ergometry,13 low-velocity graded treadmill,20 cycle ergometer exercise,15 graded stand-ups,17

Keio J Med 2003; 52 (4): 211–219

Table 1

213

Stress Testing Protocols for Persons with Stroke

Author (year)

Mode of exercise

ProtocolIndex of ﬁtness

Criteria for stopping

Moldover(1984)

supine ergometer

20 W for 3 min, then increase by 20 W every 3 min.
1 min rest period between stages. Pedaling rate at
50 rpm.

Yoshida(1985)
Majima(1985)

treadmilltreadmillChange speed every 4 min (14 m, 22 m, 29 m, 37 m,
44 m, 51 m, 59 m–66 m/min) with a grade of 0%.
Walk for 5 min at 50% of the patient’s comfortablespeed ! at 120% for 5 min ! at 100% for 5 min withan incline of 5 . Rest periods in between.

Sonoda(1989)

trunk ﬂexionextention

Sitting on a chair, ﬂexes and extends trunk at a rateof 20, 35 and 50 rpm every 3 min.

HR-O2 coeff

Hiwatari(1989)

supine ergometer

At 200 kpm and 300 kpm, perform maximal exercisethat can be done without discomfort for 3 min each.

HR, BP, DP, V̇O2

Komuro(1992)

ergometer

10 W for 2 min, then increase by 15 W every min.
Pedaling rate at 70 rpm.

AT

exhaustion, inability tomaintain the pedaling
rate.

Muraki(1992)

standing

Flex and extend upper extremities at 15 and 30 rpm
with an incline of 0 , then at 15 and 30 rpm with anincline of 15 . 3 min for each step and 3 min rest in
between.

Tsukagoshi(1993)

treadmillATunable to walk, leg
fatigue, shortness ofbreathOhkuma(1994)

repetitive
stand-ups

Walk at 5 m/min with 0% inclination, then increase
the speed 5 m/min every 30 sec. After reaching
maximum speed, the inclination is increased by 2%
every 30 sec.
Stand up from a seat height of 60 cm at a rate of
10 rpm for 4 min, then at a rate of 20 rpm for 1 min.
Lower the seat height by 5 cm every min.

ATsubjective symptoms,
f90% HRmax unable
to continue

Majima(1995)

ergometer

0 W for 3 min, then increase by 15 W/min. Pedaling
rate at 40 rpm.

AT

fatigue, ECG
abnormalities, systolic
BP f 200 mmHg

Mori
(1995)

basic bedsideactivities

Rest ! sitting ! standing ! arm elevation (10rpm) ! roll over (7 rpm) ! bridging (13 rpm) ! sit
ups (5 rpm) ! stepping (60 steps/min) ! stand-ups(10 rpm). 4 min exercise and 2 to 4 min rest in
between.

HR-O2 coeff,
V̇O2 -100

subjective symptoms,
ECG abnormalities,
BP f 200 mmHg

Hara
(1996)

single arm
ergometer

Start at 25 W, then increase by 5 W every min.

HR-O2 coeff,
V̇O2 -100

subjective symptoms,
ECG abnormalities,
BP f 200 mmHg

Macko RF
(1997)

treadmillGraded treadmill at gait velocities individualized tofunctional mobility observed during an initial zeroincline treadmill tolerance test.

HR, ECG

Tsuji(1999)

bridging activity

3 rpm for 4 min, and the rate is increased to 6, 12, 18
and 24 rpm every 4 min.

HR-O2 coeff

subjective symptoms
ECG abnormalities
lactic thresholdfatigue, inability to walkV̇O2 -100, 120

subjective symptoms,
ECG abnormalities,
BP f 200 mmHg

W: Watt(s); rpm: repetition per minute, V̇O2 -100, 120: oxygen consumption at the heart rate of 100 or 120 beats/min; BP: blood pressure;
HR-O2 -coeff: heart rate oxygen coefﬁcient; AT: anaerobic threshold; HRmax: maximal heart rate; ECG: electrocardiogram.

body bending,11 graded basic activities,12 and gradedbridging activities.14 The protocols reported so far are
summarized in Table 1. Our group has studied extensively the possibility of applying basic bedside activities
and single arm ergometry as graded testing protocols.12–14,21
Graded basic activities protocol: Patients with hemiparetic stroke routinely perform bedside activities suchas roll-over, sit-ups and stand-ups, which play an important role in stroke rehabilitation. There have been,
however, limited reports studying their cardiopulmonary stress levels in detail, except the study by Mori12
who investigated the stress levels of basic bedside activities, and proposed a new stress testing protocol.
In his pilot study, 15 patients with hemiparetic stroke
were asked to perform bedside activities at speeds
which they found comfortable, and HR and V̇O2 were214

Liu M, et al: Fitness in stroke

Fig. 1 The graded basic activities protocol. After 4 minutes of supine resting, the patient performs basic activities successively from sitting tostand-ups, each lasting 4 minutes with 2 or 4 minutes rest period in between. Blood pressure (BP), heart rate (HR) and oxygen consumption arecontinuously monitored. (Reproduced from Mori E: Jpn J Rehabil Med 1996; 33: 49–60 (in Japanese) Copyright 6 (1996), with permission fromJapanese Association of Rehabilitation Medicine)

continuously monitored to determine the stress level ofeach activity. The V̇O2 increased in the following order;
supine lying, sitting, standing, arm elevation, roll over,bridging, sit-ups, stepping and stand-ups. The HR
demonstrated almost parallel changes. By analyzing the
distribution of the repetitions per minute (RPM) for
each activity, Mori determined the RPM-80%s or the
RPMs that over 80% of the patients could follow. He
proposed a graded basic activities stress testing protocol
based on the RPM-80%s (Fig. 1).
The reproducibility of his protocol was studied inanother 17 patients. The HRs were not signiﬁcantly
different between the two measurements for all activities, and the amounts of HR increase from resting were
not statistically different except roll-over. For V̇O2 , although the absolute values were signiﬁcantly lower inthe second examination for sitting, standing and standups, the amounts of increase from the resting state were
not statistically different for all activities. Also, the HRO2 -coeff and predicted V̇O2 max were not signiﬁcantly
different between the two examinations.
Using this protocol, Mori compared HR, V̇O2 , HRO2 -coeff and predicted V̇O2 max in 52 patients withhemiparesis and 10 age-matched healthy persons. Most
(83.8%) of the patients could complete the protocol
with no serious complications. Absolute HR and HR
increases from resting were signiﬁcantly higher in thepatient group than in the control group in sitting,standing, stand-ups and stepping. The V̇O2 was not
signiﬁcantly different from the controls except forstanding and stepping, but when expressed in metabolic
equivalent (MET), or the ratio of exercise V̇O2 to resting V̇O2 ,9 it was signiﬁcantly higher in the patient groupfor sitting, standing, roll-over, stepping and stand-ups.
The HR and the V̇O2 increased linearly with each other,and linear regression lines for the two groups could be
drawn (Fig. 2). The HR-O2 -coeff and the predicted
V̇O2 max were signiﬁcantly lower in the patient group(0.240 G 0.080 vs. 0.362 G 0.069 ml  kg1  beats1 for
the HR-O2 -coeff and 24.34 G 8.84 vs. 35.18 G 7.86
ml  kg1  min1 for the predicted V̇O2 max; P < 0.01,
Student t-test), indicating lower ﬁtness level.
As far as we know, his study is the ﬁrst that systematically examined stress levels of basic activities, andgives us valuable information when we try to prescribe
a rehabilitation program for patients with stroke.
Graded bridging activity protocol: Based on the study
by Mori,12 we devised a simpler stress testing using a
graded bridging activity applicable to a wider spectrumof patients with stroke (Fig. 3). In this protocol, agraded bridging activity, deﬁned as a pelvic elevation to
maximal hip extension at several predetermined rates,
was used.14 Patients performed the bridging activity

Keio J Med 2003; 52 (4): 211–219-1
ml · kg ·
12

215

-1

min

oxygen consumption

controls:

Y= 0.409X - 24.92(R=0.98)

10

stand-ups
stand-ups

stepping
8

stepping
sit-ups

sit-upsbridging

bridgingroll-over6

arm elevation
4roll-overhemiplegics:

arm elevation
standing

sitting

Y= 0.235X-14.09(R=0.93)

standing
controls (N=10)
hemiplegics (N=52)

sittingsupinesupine

2

0
65

70

75

80

85

90

95

100

heart rate

105

110
beats · min

115-1Fig. 2 The relationship between heart rate and oxygen consumption in 52 patients with hemiparetic stroke and 10 age-matched controls. The
heart rate oxygen coefﬁcient, or the regression coefﬁcient between the heart rate and oxygen consumption is smaller in the patient group.
(Reproduced from Mori E: Jpn J Rehabil Med 1996; 33: 49–60 (in Japanese) Copyright 6 (1996), with permission from Japanese Association of
Rehabilitation Medicine)-1oxygen consumption

ml · min

600

400

200

0
time course

0 min.

4 min.

8 min.

12 min.

Bed rest

3 RPM

6 RPM

16 min.

20 min.

18 RPM

24 RPM

Blood pressure
measurement
heart rate monitoring
Expired gas analysis

12 RPM

Bridging activity
Fig. 3 Bridging activity exercise protocol. After 15 minutes of rest, the patient performs the bridging activity at a rate of 3 repetitions per
minute (RPM) for 4 minutes, and the rate was increased to 6, 12, 18, and 24 RPM every 4 minutes. Heart rate and oxygen consumption arecontinuously monitored. (Reproduced from Tsuji T, et al: Arch Phys Med Rehabil 1999; 80: 1060–1064 Copyright 6 (1999), with permission
from Elsevier Science)at a rate of 3 RPM for 4 minutes, and the rate wasincreased to 6, 12, 18 and 24 RPM every 4 minutes.
By continuously monitoring V̇O2 , and HR, the HR-O2 coeff was calculated.
When we repeated the testing twice within a week in

5 patients with hemiparesis who were over 3 months
post stroke and 5 control persons, the intraclass correlation coefﬁcients (ICC) were above 0.9 for HR, above
0.7 for V̇O2 at each stress level, and 0.75 in the controls
and 0.98 in patients for the HR-O2 -coeff. Therefore, the216

Liu M, et al: Fitness in stroke
ml · kg-1 · min -1

controls: Y = - 20.1 + 0.32X

oxygen consumption

9(R2=0.97)

8

hemiplegics: Y = -10.84 +0.20 X(R2 =0.98)

7

24RPM
18RPM

12RPM

5
4

24RPM

18RPM

6

6RPM
3RPM
supine lying

12RPM
6RPM

3RPM

controls (n=10)
hemiplegics (n=39)

supine lying

3
66 68 70 72 74 76 78 80 82 84 86 88 90
Heart ratebeats · min -1

Fig. 4 Comparison of cardiopulmonary responses between 39 hemiplegic patients (h) and 10 age-matched controls (d). Heart rate (beat/min) and oxygen consumption (m L  kg1  min1 ) increased linearly with each other in the two groups. The heart rate oxygen coefﬁcient wassigniﬁcantly less in the patient group. (Reproduced from Tsuji T, et al: Arch Phys Med Rehabil 1999; 80: 1060–1064 Copyright 6 (1999), withpermission from Elsevier Science)

test-retest reproducibility of the protocol was satisfactory.
In 44 patients with hemiparesis who were within 2
weeks of a rehabilitation admission and 10 healthy
age-matched controls, we compared HR, amounts ofincrease from the resting HR, V̇O2 , METs, and HR-O2 coeff for each RPM. All the control persons and 39 of
the 44 patients (88.6%) completed the protocol fromresting to 24 RPM. The amount of HR increase fromthe resting HR for each stress level was signiﬁcantly
greater in the patient group except at 3 RPM where no
signiﬁcant difference was found. The HR, V̇O2 , and
METs were not signiﬁcantly different. However, theHR tended to be higher, and the HR-O2 -coeff was signiﬁcantly lower in the patient group than in the control
group (0.21 G 0.08 vs. 0.29 G 0.04 ml  kg1  min1 ,P < 0.01). As shown in Fig. 4, HR and V̇O2 increased
linearly with each other in both groups, and two different linear regression lines could be drawn. Our newly
developed bridging activity protocol proved to be a reliable and valid evaluation tool of physical ﬁtness inpatients with stroke.

reported that in the young adult group, single AE
V̇O2 max corresponded to 70–80% of bilateral AE peakV̇O2 .
When 87 patients with stroke (mean age: 58.4 yr)
were compared with 35 age-matched controls (meanage: 59.9 yr) with a single AE protocol, V̇O2 max andHRmax were not signiﬁcantly different, but the HRO2 -coeff was lower in the stroke group (0.219 G 0.063
vs. 0.258 G 0.110 ml  kg1  beats1 , Student t-test,p < 0.05). Among patients with stroke, V̇O2 max andthe HR-O2 -coeff were the lowest in the wheelchairdependent group, followed by wheelchair independent, household ambulatory and community ambulatory groups (Kruscal-Wallis, P < 0.05). He also foundthat 61% of the variance of V̇O2 max could be explained by grip strength that can be easily measured indaily clinical practice.
With his protocol, most of the patients with stroke
could be stressed to a relatively high level with nomajor complications, and it can be useful clinically as amode of stress testing for these patients.
What Is the Structure of Fitness?

Single arm ergometry protocol: Arm ergometry (AE)is more widely applicable to persons with lower limb
disability than treadmill or cycle ergometer exercise.
Hara13 examined methodological issues of arm ergometry and compared the cardiopulmonary responses ofpatients with stroke to healthy persons. He studied the
reproducibility of HR and V̇O2 during a graded arm
ergometer exercise in 15 young adults (mean age: 27.7
yr, workload increment of 1 watt/3 sec) and 8 patients(mean age: 58.8 yr, workload increment of 5 watts/min),and reported that the ICCs of the two trials were over
0.83 for peak V̇O2 and 0.70 for peak HR. He also

In healthy persons, physical ﬁtness is commonly categorized by cardiopulmonary, muscular and metabolic
factors,9 but it is not known whether the same categorization applies to persons with stroke. To develop arehabilitation program more targeted to the promotionof ﬁtness in this population, it is necessary to clarify thedimensions of their ﬁtness. To our knowledge, however,no studies are available in the literature investigating
this problem except the study by our group.21 In 107
patients with hemispheric stroke, we measured multiple
parameters related to cardiopulmonary, muscular andKeio J Med 2003; 52 (4): 211–219

metabolic functions as conceptualized in the ﬁtness
model in a healthy population, and also variables related to motor impairment and disability that could
constitute another possible dimension of their ﬁtness.
We used the Stroke Impairment Assessment Set(SIAS)22,23 and the Functional Independence Measure(FIM SM )24,25 that are standardized measures of impairment and disability. As for cardiopulmonary function, we measured the distance covered by 12-minutewheelchair propulsion or walking on an indoor running
track,26 and the HR-O2 -coeff derived by having thepatients perform the graded bridging activity protocol.
With regard to muscular function, we measured grip
strength, the isometric torque of the knee extensors,
and the cross-sectional area of the thigh muscles with
CT images. As for metabolic factors, we calculated the
body mass index (BMI) and visceral fat areas as measured with a CT scanner according to van der Kooy andSeidell.27
To study the statistical structure of ﬁtness, the above
variables were subjected to a principle component analysis (PCA) followed by an orthogonal rotation of theinitially extracted components,28 which produced four
factors whose eigenvalues were greater than 1. The four
factor solutions explained 78.1% of the total variance inthe original 15 variables, and had a well-deﬁned structure. These factors could be interpreted in clinicallymeaningful ways as conceptualized before the analysis.
Factor I included grip strength, the unaffected side
SIAS quadriceps manual muscle testing (MMT) score,isometric strength of the knee extensors, and crosssectional area of the whole thigh muscles on the unaffected side. It represented the muscular function, andexplained 24.4% of the variance. Factor II was comprised of the SIAS affected side lower extremity score,
the FIM SM motor score, the ambulatory score, the affected side SIAS quadriceps MMT score, and the isometric strength of the affected side knee extensors. It
reﬂected lower extremity motor impairment and activities of daily living (ADL), and explained 24.3% of thevariance. Factor III consisted of the BMI and fat accumulation that reﬂected metabolic function, explaining
14.7% of the variance. Factor IV included the HR-O2 coeff representing the cardiopulmonary function, andexplained 14.7% of the variance. PCA of the discharge
data produced almost identical results, and the four
factor solutions explained 69.6% of the total variance.
In this way, we could demonstrate that ﬁtness inpersons with hemiparetic stroke could be categorizedon the basis of a conceptual model of ﬁtness widelyused among healthy persons if the paresis/daily living
domain is also considered. Furthermore, the possibility was suggested that we could describe their ﬁtness
domains with variables easily measured in daily clinicalpractice, i.e., grip strength (factor I: muscular), the217

SIAS and the FIM SM (factor II: paresis/ADL) and BMI(factor III: metabolic), except for factor IV (cardiopulmonary) that could only be explained by the HRO2 -coeff which requires measurement with sophisticated equipment. This justiﬁes the measurement of the
HR-O2 -coeff with an HR monitor and expired gas analyzers using a graded bridging activity protocol to better
understand the ﬁtness of patients with stroke.
What Are the Effects of Rehabilitation
Programs on Fitness?
There are several studies that examined the effects ofmuscle strengthening,29–31 aerobic training15,32,33 or a
combination of these34–36 in patients with stroke. Muscle strengthening exercise of the affected lower extremity with isokinetic strength training and progressive
resistive exercise is effective to improve muscle strengthand physical functioning such as basic activities andambulation.30,31 Eccentric contraction is more effective
than concentric contraction in improving the affected
to unaffected side knee extensor muscle strength ratio
and symmetric weight distribution.29 Aerobic training
in the chronic phase of stroke improves aerobic capacity (V̇O2 max) and systolic blood pressure response during a submaximal exercise.32 Low-level treadmill aerobic exercise training increases peak V̇O2 and decreases
energy consumption during ambulation, and is effective
to improve cardiovascular ﬁtness.33 A combination of
aerobic exercise and lower extremity muscle strengthening improves affected side muscle strength, gait
speed, physical activity and quality of life.34 Taskrelated circuit training focusing on lower extremity
muscle strength and functional tasks improves performance of locomotor tasks in chronic stroke.35 A
health promotion program consisting of aerobic exercise, muscle strengthening and ﬂexibility exercise improves general ﬁtness.36
The above studies are targeted to training muscular
and/or cardiopulmonary components of ﬁtness. Whatabout the effects of a conventional inpatient stroke
rehabilitation program on ﬁtness? Mori12 followed
the longitudinal changes of the exercise parameters
obtained with basic bedside activities protocol in 13
patients involved in an inpatient stroke rehabilitation
program over a period of 4 weeks. The HRs tended
to be lower in the second examination for all activities. The absolute values were signiﬁcantly lower forbridging and stand-ups, and the amounts of increase
from the resting values were signiﬁcantly lower forarm elevation, roll-over, bridging and stand-ups. In
contrast, the V̇O2 values were not signiﬁcantly different
between the two measurements both for the absoluteand the relative values. The indices of cardiopulmonaryﬁtness were signiﬁcantly higher in the second examina-

218

tion (0.214 G 0.069 vs. 0.257 G 0.091 ml  kg1  beats1
for the HR-O2 -coeff and 22.47 G 7.49 vs. 26.93 G 10.02
ml  kg1  min1 for predicted V̇O2 max; P < 0.05, paired
t-test).
In another study, we studied the longitudinal changes
in ﬁtness parameters in 30 patients with hemiparesis
undergoing a conventional stroke rehabilitation program 5 days a week using the graded bridging activity
protocol.14 The absolute HR was signiﬁcantly lower at
each RPM level and the HR-O2 -coeff was signiﬁcantly
greater in the 2nd examination.
Thus, ﬁtness appears to improve during a conventional rehabilitation program, but few studies haveso far analyzed systematically the changes of various
dimensions of ﬁtness. We therefore examined in 107
patients with hemiparetic stroke whether the principle

Liu M, et al: Fitness in stroke

component (PC) scores of the four components of ﬁtness described above can be used to document changes
of ﬁtness level after an inpatient stroke rehabilitation
program.21 As a result, the PC score for Factor I (muscular) decreased and those for factor II (paresis/ADL)
and IV (cardiopulmonary) increased signiﬁcantly atdischarge, indicating improvement in these domains ofﬁtness. In contrast, the PC score for Factor III (metabolic) did not change signiﬁcantly. Fig. 5 shows scattergraphs of the PC scores for each patient at admission
and at discharge. An ellipse contains 95% of the scatterplots, and all the ellipses moved in the directions ofmore normal areas at discharge, suggesting improvement. In this way, we could demonstrate that PC scores
were useful not only to characterize but also to follow
longitudinal changes of individual patients. In the fu-

Fig. 5 a) A scatter graph of the principle component scores of Factor I (muscular) and Factor II (paresis/activities of daily living; ADL) at
admission and at discharge. 95% of the scatter plots are concentrated statistically in an ellipse. b) A scatter graph of the principle componentscores of Factor I (muscular) and Factor III (metabolic function) at admission and at discharge. c) A scatter graph of Factor I (muscular) andFactor IV (cardiopulmonary function) at admission and at discharge. h, admission; d, discharge. All the ellipses moved in the directions ofmore normal areas at discharge, indicating improvement. (Reproduced from Tsuji T, et al: Clin Rehabil 2003 (in press), with permission from
Arnold Publishers)Keio J Med 2003; 52 (4): 211–219

ture, it would be necessary to prescribe a more speciﬁctraining program to improve the ﬁtness dimensions withlower scores on an individual basis.

219

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