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Cardiac Rehab Research

A single blind randomized controlled trial to evaluate the effects of a cardiac rehabilitation programme in the non-acute ischaemic stroke population.

Lennon, O., Carey, A., Stephenson, J., Gaffney, N., Blake, C. (2006).
Physical Therapy Reviews (11) 211-212.

In 2003 diseases of the circulatory system accounted for 10,984 of all deaths in Ireland or an annual rate of 2.8 per 1,000 population. Of these 5,648 (20%) were due to Cardiovascular Disease (CVD) and 2,255 (8%) to Cerebrovascular Disease (CeVD)1. While CVD and CeVD death rates continue to fall, the prevalence in the population of those at high risk of recurrence of CVD and CeVD increases, as does the need for disease management, secondary prevention and cardiac rehabilitation2 .

Both coronary artery disease (CAD) and ischaemic stroke share links to many of the same predisposing, potentially modifiable risk factors (hypertension, abnormal blood lipids and lipoproteins, cigarette smoking, physical inactivity, obesity and diabetes mellitus). Modification of multiple risk factors through a combination of lifestyle interventions and appropriate pharmacological therapy is now recognised as the cornerstone of initiatives aimed at prevention of recurrent stroke and acute cardiac events in stroke survivors4-6.


Physical inactivity is a major risk factor for developing heart disease and stroke12. Stroke patients are known to have low endurance to exercise, which when compounded by increased difficulty moving associated with hemiparesis, and decreased activity levels contributes to a poor outcome13.


Given the proven benefits of regular physical activity on cardiovascular disease risk factors in able bodied individuals7, in the post myocardial infarct and coronary grafting populations 8,9, the support for cardiovascular training in stroke survivors is growing, and the need for research into the effects of such programmes has recently been highlighted as a priority by the American Heart Association (AHA)3, a recent Cochrane Review10 and The Irish Heart Foundation Council on Stroke11.

In a scientific statement on physical activity after stroke, the AHA (2004) recommend the use of aerobic conditioning post stroke to improve cardiovascular risk factors as part of a comprehensive stroke and cardiovascular risk reduction programme 14.  Secondary preventative programmes to date15,16 have recommended exercise counselling as part of their programmes but as Hill et al.17 report, only 7% of patients discharged from rehabilitation post stroke meet the criteria for community walking ( e.g. a speed that would allow them to cross a road safely), few stroke patients are able to avail of cardiovascular training through the traditional method of fast walking or treadmill training.

A cycle ergometer with adaptive devices as necessary can allow aerobic fitness training in this population 18.

The purpose of this study was to evaluate the benefits of a 10 week cardiac rehabilitation programme for the non-acute ischaemic stroke population.

Methods: 48 subjects >1 year post ischaemic stroke were stratified for age and sex and randomly assigned to an intervention group or a control group by concealed allocation. The intervention group received two life style classes and 16 sessions of 30 minutes cycle ergometry training set at 50-60% of their maximal heart rate in a controlled environment. The primary outcome measures, recorded by an independent assessor blinded to the group allocation were (1) cardiac risk score based on age, B.P., diabetic status and lipid profiles (2) VO2 and Borg Rate of Perceived Exertion which were assessed during a steady state 3 minute standardised cycle ergometry test. Other outcome measures included self-administered Hospital Anxiety and Depression Scale (HAD), Frenchay Activity Index and spirometry.

Results: When compared with independent t tests, the intervention subjects showed significantly greater improvement at 10 week follow-up than controls infitness parameters. Within group comparison showed a significant improvement in the HAD depression subscale in the intervention group alone.

Conclusion: Non-acute ischaemic stroke patients can improve their cardiovascular fitness and reduce their risk of developing coronary heart disease with a 10 week cardiac rehabilitation programme including cycle ergometry. The intervention was also associated with improvements in self-reported quality of life.

References:

  1. Central Statistics Office, 2004, http://www.cso.ie
  2. Ireland ’s Changing Heart, Heart Health Task Force, Department of Health and Children,2003.
  3. Gordon NF, Gulanick M, Costa F, Fletcher G, Franklin BA, Roth EJ & Shephard T (2004).Physical activity and exercise recommendations for Stroke survivors.American Heart Association Scientific Statement.Circulation, (109), 2031-2041
  4.  Adams RJ, Chimowitz MI, Alpert JS, Awad IA, Cerqueria MD, Fayad P, Taubert KA. AHA/ASA Scientific Statement. Coronary Risk Evaulation in patients with Transient Ischemic Attack and Ischemic Stroke. A Scientific Statement for Healthcare Professionals from the Stroke Council and the Council on Clinical Cardiology of the American Heart Association/American Stroke Association. Circualtion 2003; 108: 1278-1290
  5. Chalmers J,Chapman N.Challenges for the prevention of primary and secondary stroke: the importance of lowering blood pressure and total cardiovascular risk. Blood Press2001;10(5-6):344-51
  6. Wolf PA, Clagett GP, Easton JD et al. Preventing ischemic stroke in patients with prior stroke and transient ischemic attack: A statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke 1999; 30: 1991-1994
  7. Pearson TA, Blair SN, Daniels SR, Eckel RH, Fair JM, fortmann SP, Franklin BA, Goldstein LB, Greenland P, grundy SM, Hong y, Houston miller N, Lauer RM, ockene IS, Sacco RL, Sallis JF, Smith SC, Stone NJ & Taubert KA (2002).AHA Guidelines for primary prevention of cardiovascular disease and Stroke: 2002 update.Circulation.(106), 388-391.
  8. Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N & Ebrahim S.Exercise-based rehabilitation for coronary heart disease.The Cochrane Database of Systemic Reviews 2001, Issue 1.Art.No:CD001800.DOI:10.1002/14651858.CD001800.
  9. Taylor RS, Brown A, Ebrahim S, Joliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR & Oldridge N (2004).
    Exercise-based rehabilitation for patients with coronary heart disease:
    systematic review and meta-analysis of randomized controlled trials.
    The American Journal of Medicine, (116), 682-692.
  10. Saunders DH, Greig CA, Young A,Mead GE. Physical fitness training for stroke patients. The Cochrane Database of Systematic Reviews2004, Issue 1. Art. No: CD003316.pub2. DOI: 10.1002/14651858.CD003316.pub2.
  11. Towards excellence in stroke care in Ireland, Council on Stroke, Irish heart Foundation, June 16, 2000..
  12. Fletcher FG, Blair SN, Blumenthal J, et al: Statement on exercises, benefits, and recommendation for physical activity programs for all Americans: A statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association. Circulation: 86: 340-344,1992.
  13. Potempa K, lopez M, Braun, l, Szidon P, Fogg L, Tincknell T. Physiological Outcomes of Aerobic Training in hemipareitic Stroke patients. Stroke. 1995; 26:101-105.
  14. Gordon NF, Gulanick M, Costa F, Fletcher G, Franklin BA, Roth EJ, Shephard T. AHA/ASA Scientific Statement.Physical activity and exercise recommendations for stroke survivors.An American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity and Metabolism; and the Stroke Council.Circulation 2004; 109: 2031-2041
  15. Ovbiagele B, Saver J.L, Fredieu A, Suzuki S, McNair N, Dandekar A, Razinia T, Kidwell CS. PROTECT A coordinated stroke treatment program to prevent recurrent thromboembolic events. Nuerology 2004; 63:1217-1222.
  16. Greenlund KJ, Giles WH, Keenan Nl, Croft JB & Mensah GA (2002).Physician advice and, patient actions and health-related quality of life in secondary prevention of stroke through diet and exercise.Stroke.(33), 565-571.
  17. Hill K, Ellis P, Bernhardt J, Maggs P, Hull S. Balance and mobility outcomes for stroke patients: a comprehensive audit. Aust J Physiother. 1997;43(3):173-180.
  18. Carr J & Shepard R .Stroke Rehabilitation: Guidelines for exercise and training to optimise motor skill. 2002 Philadelphia: Butterworth Heinemann.

 
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