Pilot study shows improvements in cardiac and overall health status

A cardiovascular (CV) rehabilitation program with an emphasis on aerobic exercise boosted CV endurance, health status, and quality of life (QoL) for stroke survivors, and benefits were maintained at 6 months, researchers reported.

In the pilot study at a single North Carolina medical center, 24 participants (ages 33 to 81) who had a stroke from 3 months to 10 years earlier were enrolled in a cardiac rehab program that included aerobic sessions (30 to 51 minutes long) three times a week for 3 months, according to Elizabeth W. Regan, PhD, DPT, of the University of South Carolina in Columbia, and co-authors.

Exercise-based cardiac rehab had significant impacts on CV endurance pre-program to post-program, with maintenance at 6-month follow-up among 18 participants, they reported in the Journal of the American Heart Association. Specifically, participants experienced:

  • Improvement in 6-minute walk test by an average of 61.92 m (95% CI 33.99 to 89.84 m).
  • Improvement in maximum metabolic equivalents by a median of 3.6.
  • Improvement in five times sit to stand (functional strength) by a median of 2.85 s from pre- to post-program.

Additionally, 83% of the 18 follow-up patients reported continued exercise, Regan’s group noted, and patients overall reported better QoL, including improvements in emotional health.

“Through this study, we hoped to improve controllable risk factors for stroke survivors, and potentially prevent future stroke and cardiac events,” Regan said in a press release. “Increasing physical activity is an important way to prevent stroke, and we wanted to see whether the rehab that patients receive after surviving a heart attack could have similar positive outcomes for patients who survive a stroke.”

Many stroke patients receive physical therapy (PT) immediately after the event, but exercise intervention often gets left out because of time constraints or an emphasis on regaining functional skills, the authors noted. Professional groups, such as the American Heart Association (AHA), the AHA/American Stroke Association, and the Heart and Stroke Foundation of Canada, call for stroke patients to engage in physical activity and exercise for rehab purposes.

But once the in-person PT stops, stroke survivors are often left to their own devices with “self- directed individual activity,” leaving them in a deconditioned state, Regan’s group noted. “Based on these preliminary findings, we hope prescribing cardiac rehab will be considered for all patients following a stroke, as it is for patients after a heart attack,” they added. “We need to place value on exercise as medicine. Exercise is health, and it is important for every individual, regardless of physical limitations or age. Hopefully, increasing physical activity can be one of the first steps to improving overall health following a stroke.”

The authors enrolled subacute and chronic stroke survivors (mean age 62.2; 19% men; 17% White) into a standard 12-week exercise-based cardiac rehab program. Most of the patients (15%) experienced ischemic stroke with a mean time since stroke of almost 30 months. The most common comorbidity was high blood pressure (83.3%).

The study began in Aug. 2018, and patients were followed up through Feb. 2020. Each exercise session had moderate aerobic activity with additional optional activities such as strengthening, stretching, or relaxation. “Although components varied by session and individual, the general format was warm-up, cardiovascular endurance activities (treadmill, recumbent step machine, recumbent bike, and over ground walking), cooldown, and optional activities,” they explained.

The target exercise rate of perceived exertion (RPE) levels were set from 11 (“light”) to 14 (“somewhat hard”), on a scale of 6 to 20, and progression was determined by participant-reported RPE.

Among those who completed the program, 29% reported a history of multiple strokes and 29% reported previously participation in a rehab program for a traditional cardiac diagnosis. The average number of sessions in the current study per person who completed was 25.25 (95% CI 22.91 to 27.92). These participants also averaged 38.93 (95% CI 36.54 to 41.31) exercise minutes per session and met RPE targets of 11 to 14 across all sessions, according to the authors.

“There were no safety events related to exercise intensity, and all participants met the prescribed RPE ranges,” they noted.

In terms of emotional health, the program did not lead to significant changes for patients who underwent pre-program screening for depression, but “many participants noted improvements in emotional health, including reduced depression, contributions to a positive attitude, and improved self-perception. Participants noted a new or renewed sense of enthusiasm for exercise or for engaging in activities and feeling more confident about their abilities,” Regan and co-authors reported.

Finally, at 6-month follow-up, the participants who said they engaged in exercise at least once a week opted for walking most often (50%), followed by strengthening and aerobics at a gym.

Study limitations included the single-center pilot design and the fact that the majority of the participants were White men. The authors also pointed out that weekly organized educational sessions were on offer for the participants, but “Study participants’ failure to use the available education sessions was a missed opportunity for additional potential behavior change.” However, confusion among the staff as to the participant eligibility for these sessions may have been an issue, they conceded.

This month, the Canadian Partnership for Stroke Recovery and the Canadian Institutes of Health Research released the “AEROBICS 2019 Update,” designed to make it “easier for clinicians to screen for, and prescribe, aerobic exercise in stroke rehabilitation.”

  1. Aerobic exercise-based cardiac rehab for survivors of stroke had a positive impact on cardiovascular (CV) endurance, functional strength, walking capability, and emotional health.

  2. Improvements in CV endurance and functional strength were maintained at 6-month follow-up.

Shalmali Pal, Contributing Writer, BreakingMED™

The study was supported by the University of South Carolina (USC) Behavioral-Biomedical Interface Program, a 2019 American Heart Association (AHA) Pre-Doctoral Fellowship, a 2018 American Physical Therapy Association Health Policy and Administration Research Grant, a 2019 USC Support to Promote Advancement of Research and Creativity Grant, the AHA, the Foundation for Physical Therapy Research, and the Arnold Fellowship from the Arnold School of Public Health at USC.

Regan and co-authors reported no relationships relevant to the contents of this paper to disclose.

Cat ID: 38

Topic ID: 82,38,730,8,38,192,925