Advertisement

Exercise Programs Delivered According to Guidelines Improve Mobility in People With Stroke: A Systematic Review and Meta-analysis

Published:August 08, 2019DOI:https://doi.org/10.1016/j.apmr.2019.06.015

      Abstract

      Objective

      To determine if prescribing a combined aerobic and resistance training exercise program in accordance with American Stroke Association physical activity guidelines improves mobility and physical activity levels of people after stroke.

      Data Sources

      Online database search from earliest available date to August 27, 2018.

      Study Selection

      Randomized controlled trials evaluating the effectiveness of exercise programs prescribed in accordance with guidelines for improving mobility and physical activity levels in adults with subacute or chronic stroke.

      Data Extraction

      Two independent reviewers completed data extraction. Risk of bias was assessed using the Physiotherapy Evidence Database Scale, and overall quality of evidence was assessed using the Grades of Research, Assessment, Development, and Evaluation approach.

      Data Synthesis

      Data was pooled from a total of 499 participants for meta-analysis. There was high-level evidence that exercise programs adhering to guidelines improve habitual walking speed (mean difference, 0.07m/s; 95% CI, −0.01 to 0.16) and walking endurance (mean difference, 39.2m, 95% CI, 17.2-61.2). A sensitivity analysis demonstrated high-level evidence of improvements in walking endurance (mean difference, 51.1m; 95% CI, 19.96-82.24) and moderate-level evidence of improvements on the Timed Up and Go test (standardized mean difference, 0.57; 95% CI, 0.16-0.99). No differences were detected for other mobility outcome measures or physical activity levels. Adherence was high and few adverse events were reported.

      Conclusion

      A combined exercise program comprising aerobic and resistance training that adheres to the American Stroke Association guidelines is safe and should be prescribed in addition to usual care to improve mobility. Further research is needed to understand the relationship between exercise programs and behavior change requirements to improve long-term physical activity levels.

      Keywords

      List of abbreviations:

      ASA (American Stroke Association), FITT (frequency, intensity, time, and type), MD (mean difference), PEDro (Physiotherapy Evidence Database), SMD (standardized mean difference)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Roger V.
        • Go A.
        • Lloyd-Jones D.
        • et al.
        Heart disease and stroke statistics- 2012 update: a report from the American Heart Association.
        Circulation. 2012; 125: e2-e220
        • English C.
        • Bernhardt J.
        • Hillier S.
        Circuit class therapy and 7-day-week therapy increase physiotherapy time, but not patient activity: early results from the CIRCIT trial.
        Stroke. 2014; 45: 3002-3007
        • Billinger S.
        • Arena R.
        • Bernhardt J.
        • et al.
        Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2014; 45: 2532-2553
        • Pharr J.
        • Bungum T.
        Health disparities experienced by people with disabilities in the United States: a Behavioral Risk Factor Surveillance System study.
        Glob J Health Sci. 2012; 4: 99-108
        • Veerbeek J.
        • Koolstra M.
        • Ket J.
        • van Wegen E.
        • Kwakkel G.
        Effects of augmented exercise therapy on outcome of gait and gait-related activities in the first 6 months after stroke: a meta-analysis.
        Stroke. 2011; 42: 3311-3315
        • Billinger S.
        • Boyne P.
        • Coughenour E.
        • Dunning K.
        • Mattlage A.
        Does aerobic exercise and the FITT principle fit into stroke recovery?.
        Curr Neurol Neurosci Rep. 2015; 15: 519
        • Banks G.
        • Bernhardt J.
        • Churilov L.
        • Cumming T.
        Exercise preferences are different after stroke.
        Stroke Res Treat. 2012; 2012: 890946
        • Pollock A.
        • Baer G.
        • Campbell P.
        • et al.
        Physical rehabilitation approaches for the recovery of function and mobility following stroke.
        Cochrane Database Syst Rev. 2014; 4CD001920
        • Saunders D.
        • Sanderson M.
        • Hayes S.
        • et al.
        Physical fitness training for stroke patients.
        Cochrane Database Syst Rev. 2016; 3CD003316
        • Ammann B.
        • Knols R.
        • Baschung P.
        • de Bie R.
        • de Bruin E.
        Application of principles of exercise training in sub acute and chronic stroke survivors: a systematic review.
        BMC Neurology. 2014; 14: 167
        • MacKay-Lyons M.
        • Makrides L.
        Cardiovascular stress during a contemporary stroke rehabilitation program: is the intensity adequate to induce a training effect?.
        Arch Phys Med Rehabil. 2002; 83: 1378-1383
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • Group P.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        J Clin Epidemiol. 2009; 62: 1006-1012
        • Scottish Intercollegiate Guidelines Network (SIGN)
        Healthcare improvement 2014.
        (Available at:)
        http://www.sign.ac.uk/methodology/filters.html
        Date accessed: February 25, 2019
        • Allen L.
        • Hasso A.
        • Handwerker J.
        • Farid H.
        Sequence-specific MR imaging findings that are useful in dating ischemic stroke.
        Radiographics. 2012; 32 ([discussion 1297-1297]): 1285-1297
        • Stroke Foundation
        Clinical Guidelines for Stroke Management 2017.
        (Available at:)
        https://strokefoundation.org.au/
        Date accessed: February 25, 2019
        • Maher C.
        • Sherrington C.
        • Herbert R.
        • Moseley A.
        • Elkins M.
        Reliability of the PEDro scale for rating quality of randomized controlled trials.
        Phys Ther. 2003; 83: 713-721
        • Yong Hee L.
        • Soo Hyun P.
        • Eun Sun Y.
        • et al.
        Effects of combined aerobic and resistance exercise on central arterial stiffness and gait velocity in patients with chronic poststroke hemiparesis.
        Am J Phys Med Rehabil. 2015; 94: 687-695
        • Dennett A.
        • Peiris C.
        • Shields N.
        • Prendergast L.
        • Taylor N.
        Moderate-intensity exercise reduces fatigue and improves mobility in cancer survivors: a systematic review and meta-regression.
        J Physiother. 2016; 62: 68-82
        • Langhammer B.
        • Stanghelle J.
        • Lindmark B.
        Exercise and health-related quality of life during the first year following acute stroke. A randomized controlled trial.
        Brain Inj. 2008; 22: 135-145
        • Langhammer B.
        • Stanghelle J.K.
        • Lindmark B.
        An evaluation of two different exercise regimes during the first year following stroke: a randomised controlled trial.
        Physiother Theory Pract. 2009; 25: 55-68
        • Langhammer B.
        • Lindmark B.
        • Stanghelle J.K.
        Physiotherapy and physical functioning post-stroke: exercise habits and functioning 4 years later? Long-term follow-up after a 1-year long-term intervention period: a randomized controlled trial.
        Brain Inj. 2014; 28: 1396-1405
        • Moore S.
        • Hallsworth K.
        • Jakovljevic D.
        • et al.
        Effects of community exercise therapy on metabolic, brain, physical, and cognitive function following stroke: a randomized controlled pilot trial.
        Neurorehabil Neural Repair. 2015; 29: 623-635
        • Duncan P.
        • Studenski S.
        • Richards L.
        • et al.
        Randomized clinical trial of therapeutic exercise in subacute stroke.
        Stroke. 2003; 34: 2173-2180
        • Marzolini S.
        • Brooks D.
        • Oh P.
        • et al.
        Aerobic with resistance training or aerobic training alone poststroke: a secondary analysis from a randomized clinical trial.
        Neurorehabiln Neural Repair. 2018; 32: 209-222
        • Lee M.
        • Kilbreath S.
        • Singh M.
        • et al.
        Comparison of effect of aerobic cycle training and progressive resistance training on walking ability after stroke: a randomized sham exercise-controlled study.
        J Am Geriatr Soc. 2008; 56: 976-985
        • Pang M.
        • Eng J.
        • Dawson A.
        • McKay H.
        • Harris J.
        A community-based fitness and mobility exercise program for older adults with chronic stroke: a randomized, controlled trial.
        J Am Geriatr Soc. 2005; 53: 1667-1674
        • Mead G.
        • Greig C.
        • Cunningham I.
        • et al.
        Stroke: a randomized trial of exercise or relaxation.
        J Am Geriatr Soc. 2007; 55: 892-899
        • Matchar D.
        • Duncan P.
        • Samsa P.
        • et al.
        The Stroke Prevention Patient Outcomes Research Team. Goals and methods.
        Stroke. 1993; 24: 2135-2142
        • Perera S.
        • Mody S.
        • Woodman R.
        • Studenski S.
        Meaningful change and responsiveness in common physical performance measures in older adults.
        J Am Geriatr Soc. 2006; 54: 743-749
        • Tang A.
        • Eng J.
        • Rand D.
        Relationship between perceived and measured changes in walking after stroke.
        J Neurol Phys Ther. 2012; 36: 115-121
        • Doyle L.
        • Mackay-Lyons M.
        Utilization of aerobic exercise in adult neurological rehabilitation by physical therapists in Canada.
        J Neurol Phys Ther. 2013; 37: 20-26
        • Radak Z.
        • Chung H.Y.
        • Koltai E.
        • Taylor A.
        • Goto S.
        Exercise, oxidative stress and hormesis.
        Ageing Res Rev. 2008; 7: 34-42
        • Sacco R.L.
        • Adams R.
        • Albers G.
        • et al.
        Guidelines for prevention of stroke in patients with ischaemic stroke or transient ischaemic attack: a statement for health care professionals form the American Heart Association/American Stroke association council on stroke.
        Circulation. 2006; 113: e409-e449
        • Prior P.
        • Suskin N.
        Exercise for stroke prevention.
        Stroke Vasc Neurol. 2018; 3: 59-68
        • Hendrey G.
        • Holland A.
        • Mentiplay B.
        • Clark R.
        • Williams G.
        Do trials of resistance training to improve mobility after stroke adhere to the American College of Sports Medicine guidelines? A systematic review.
        Arch Phys Med Rehabil. 2018; 99: 584-597
        • Pang M.
        • Eng J.
        • Dawson A.
        • Gylfadottir S.
        The use of aerobic exercise training in improving aerobic capacity in individuals with stroke: a meta-analysis.
        Clin Rehabil. 2006; 20: 97-111
        • Salter K.
        • Musovic A.
        • Taylor N.
        In the first 3 months after stroke is progressive resistance training safe and does it improve activity? A systematic review.
        Top Stroke Rehabil. 2016; 23: 366-375
      1. Pescatello L. ACSM’s guidelines for exercise testing and prescription. 9th ed. Lippincott, Williams and Wilkins, Philadelphia, PA2014
        • English C.
        • Manns P.
        • Tucak C.
        • Bernhardt J.
        Physical activity and sedentary behaviors in people with stroke living in the community: a systematic review.
        Phys Ther. 2014; 94: 185-196
        • English C.
        • Healy G.
        • Coates A.
        • Lewis L.
        • Olds T.
        • Bernhardt J.
        Sitting and activity time in people with stroke.
        Phys Ther. 2016; 96: 193-201
        • Ivey F.
        • Hafer-Macko C.
        • Macko R.
        Exercise training for cardiometabolic adaptation after stroke.
        J Cardiopulm Rehabil Prev. 2008; 28: 2-11
        • Morris J.
        • Oliver T.
        • Kroll T.
        • Macgillivray S.
        The importance of psychological and social factors in influencing the uptake and maintenance of physical activity after stroke: a structured review of the empirical literature.
        Stroke Res Treat. 2012; 2012: 195249