Stroke and its aftermath remain a leading cause of long-term disability in the United States, a fact that fitness professionals should be well-aware of. Each year, in the United States alone, approximately 700,000 people suffer a stroke. 50% of men and women under the age of 65 who suffer a stroke die within 8 years. Stroke survivors are often deconditioned and predisposed to a sedentary lifestyle that limits performance of activities of daily living, increases potential falls, and may contribute to a heightened risk of recurrent stroke and cardiovascular disease. This creates a vicious cycle of further decreased activity and greater exercise intolerance, leading to secondary complications such as reduced cardiorespiratory fitness, muscle atrophy and osteoporosis.
Recent research studies have shown that aggressive rehabilitation increases aerobic capacity and sensorimotor function. 3 major rehabilitation goals for the stroke patient are: preventing complications of prolonged inactivity, decreasing recurrent stroke and cardiovascular events, and increasing aerobic fitness. To achieve the first rehabilitation goal, the stroke patient needs to initiate a physical conditioning regimen designed to regain pre-stroke levels of activity as soon as possible. The second goal will be enhanced once the first goal has been enacted. Diet and lifestyle changes are highly effective factors in future event/illness occurrence. The third rehabilitation goal for the post-stroke client typically begins gradually, building upon intensity and time as strength increases.
Extolling The Virtues
Clearly, stroke survivors can benefit from counseling on participation in physical activities and exercise training. Here is where trainers can bridge that gap often left by physicians not well versed in fitness programming. Evidence now suggests that the exercise trainability of stroke survivors may be comparable, in many ways, to that of their age-matched, healthy counterparts.
Previous studies have demonstrated the trainability of stroke survivors and documented beneficial physiological, psychological, sensorimotor, strength, endurance, and functional effects of various types of exercise. Moreover, data research involving stroke and able-bodied subjects have unequivocally illustrated the beneficial impact of regular physical activity on multiple cardiovascular disease risk factors. There is currently ample evidence that such benefits are likely to translate into a reduced risk for mortality from stroke and cardiac events.
Starting Cardio and Resistance Training
An aerobic conditioning program can enhance glucose regulation and promote decreases in body weight and fat stores, blood pressure, C-reactive protein, and levels of total blood cholesterol. Exercise also improves coronary artery endothelial function. All of these attributes will serve a client well as he proceeds through the post-stroke exercise and rehabilitation. Working with weights has likewise been found to benefit post-stroke clients. Resistance training can increase strength and muscle mass, changes which can mean increased mobility, greater independence and better function with daily activities. As with aerobic exercise, weight workouts involve intensity, duration and frequency, all subject to the needs and abilities of the client.
Treadmill training appears to offer several distinct advantages in the exercise rehabilitation of individuals who have suffered a stroke. Walking, even with assisted devices, is something most individuals do every day, and stroke survivors with reasonable mobility should be no exception. The use of handrail support and “unweighting” devices (harnesses that “lift” patients, effectively decreasing their weight) allows patients to walk on a treadmill who might otherwise be unable to exercise. When working with patients suffering from post-stroke residual gait deviations, increasing the treadmill grade while still maintaining a comfortable speed allows the client to vary the workout’s intensity.
In addition to the exercises themselves, trainers can benefit from some of the science behind post-stroke rehabilitation. A simple equation to keep in mind is:
Stroke recovery = neuroplasticity + repetition + consistency.
Neuroplasticity refers to the brain’s natural ability to rewire itself by forming new connections in healthy parts of the brain. These connections take over the responsibilities of the damaged part of the brain, such as arm or leg function. The only thing it needs from the participant is repetition.
Repetition is the fuel that helps the brain rewire itself. Without this fuel, the brain loses its ability to fully repair. The more these movements are repeated, the stronger those connections will become, and the more adept the patient will become at moving.
Fueling the brain with repetitive practice helps the rewiring process, but this fuel needs to be provided on a consistent basis. Without consistency, the full benefit of the exercises cannot be realized. If too much time passes between each exercise session, the new connections in the brain begin to weaken. For this reason, sticking with an average stroke rehab regimen consistently will yield much better results than practicing an elaborate regimen infrequently. Therefore, as a trainer creates a client’s workout regimen, setting realistic goals will encourage him to stick with the program.
Traditional stroke rehabilitation programs emphasize functional training as a means of helping the individual gain and maintain as much independence as possible. Training in the performance of mobility and personal care tasks, together with attempts to improve muscle strength and coordination, continue to form the basis of most rehabilitation programs. The heightened degree of physical skill required to perform these tasks, and the physiological stress placed on the deconditioned individual’s cardiovascular system while performing activities of daily living, are very real. Studies suggest that a positive training effect is likely to occur when these movements are performed in a careful and well-thought-out manner.
Keeping Motivation High
Many stroke survivors are put off by a typical physical activity prescription of 30–45 minutes of aerobic exercise, 5-7 days a week. Physiatrist Dr. Elizabeth Pegg Frates is Assistant Director of Medical Education for the Institute of Lifestyle Medicine, and a clinical instructor in the Department of Physical Medicine and Rehabilitation, both at Harvard School of Medicine. She emphasizes how most survivors are capable of some activity depending upon their functional abilities.
“The exercise prescription needs to be individualized for each survivor based on interests, strengths and current level of fitness,” Dr. Frates says. On the downside, just as there are ways to encourage survivors, there are also ways to discourage them. “Doing too much too fast is a sure way to de-motivate someone…It’s a set-up for failure. Successful small steps are the way to produce long-lasting change….Varying the type of physical activity can be one way to keep survivors motivated,” she suggests.
Finding What Works
In the book, Life After Stroke: The Guide to Recovering Your Health and Preventing Another Stroke, the authors have created four categories that can guide personal trainers with selecting an appropriate physical activity for a client:
- Severe functional limitations
- Moderate functional limitations
- Mild functional limitations
- No functional limitations
Those with severe limitations (e.g., paralyzed on one side of the body and/or spending extended periods of time in bed) can safely perform their exercises sitting in a chair, and with assistance be able to do neck stretches, knee lifts, ankle rotations, and flexion of the elbows / wrists on the unaffected side of the body.
Those with moderate limitations (e.g., significant weakness in a limb) may be able to engage in aquatic-based physical activity, where the affected limbs are lighter. Similarly, the use of a recumbent stationary bike with assistance from a trainer, or even by securing a Velcro strap to keep the affected foot on the pedal, is a creative option for some.
Those who can move all four limbs despite weakness in one or two of them (mild limitations) have even more options, including swimming and walking or using a recumbent stationary bike or stair stepper.
A structured exercise program can help stroke survivors recover not only physically but mentally as well. An in-depth analysis of 13 clinical trials found that exercise therapy was beneficial for stroke patients’ “cognition.” Cognition refers to vital mental processes such as thinking, learning, understanding and remembering. A stroke, which temporarily cuts off blood flow to the brain, can impair those abilities.
Lauren Oberlin, a graduate student at the University of Pittsburgh, led the study that demonstrated these results. She said the findings confirm the value of exercise after a stroke. “It can improve mobility, strength and quality of life, as well as cognition,” Oberlin said. Such a mental boost, she noted, may give stroke patients “additional motivation” to maintain an exercise program. Other research points to several possible reasons why post-stroke exercises can benefit mental alertness. Exercise may improve blood flow to the brain, thereby promoting the growth of new brain cells and connections among those cells. Exercise may also enhance self-confidence and independence, thereby reducing depression and anxiety.
The most effective workouts offer patients a variety of exercises aimed at strength, balance, stretching and aerobic fitness — the kind, Oberlin noted, that “gets your heart rate up and makes you sweat.” Keeping in mind that many individuals were deconditioned even before suffering a stroke, such workouts need not be overly intense. For many, a simple walk is highly effective, enjoyable and non-threatening.
You Can Make A Difference
Other factors that influence a post-stroke level of activity include intrinsic motivation and mood, adaptability and coping skills, severity and type of preexisting /acquired medical comorbidity, medical stability and physical endurance levels. As a personal trainer begins designing a rehabilitation program, keeping these additional factors in mind will benefit not only the client, but will strengthen the trainer-client bond.
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