by Liam Johnson
Earlier this year, I was invited to present an Exercise and Sports Science Australia (ESSA) webinar on stroke rehabilitation. ESSA is the peak national body that represents exercise physiologists, exercise scientists and sports scientists. ESSA has a vision to improve the health and well-being of Australians through sport and exercise, and has a membership of over 6000 nationally, including over 4000 exercise physiologists focused on the prevention and management of chronic disease. The opportunity to present evidence for exercise training after stroke, the current post-stroke exercise recommendations, and disseminate my own research to such a forum was an exciting prospect.
During the planning of the webinar, I brought in Wayne Dite, an experienced exercise physiologist based at Royal Talbot Hospital, to co-present. I believed Wayne’s extensive clinical experience would balance my theoretical and research knowledge to ultimately deliver a high quality webinar. Our aim was to present a mix of research evidence supporting clinical practice, and clinical know-how to build capacity for attendees to implement the evidence in the clinical environment. This was framed within the context of the recently (and most timely) released Australian Clinical Guidelines for Stroke Management. These guidelines make a series of recommendations for the promotion of physical activity and commencement of cardiorespiratory fitness training after stroke. In strong support of our work, the guidelines state that rehabilitation should include:
- Individually tailored exercise interventions to improve cardiorespiratory fitness (CRF); and
- All stroke survivors should commence cardiorespiratory training during their inpatient stay, and should be encouraged to participate in regular physical activity regardless of level of disability.
The webinar was very well attended, with over 100 registered participants. After a brief introduction into what is stroke and the significance of stroke in Australia, I presented the best available evidence for physical fitness training (i.e. cardiorespiratory exercise, muscle strengthening) for stroke. I largely drew upon the 2016 Cochrane review ‘Physical fitness training for stroke survivors’.
In brief, the evidence tells us that cardiorespiratory fitness training can improve exercise ability and walking after stroke and a mix of cardiorespiratory fitness training and muscle-strengthening exercises improve walking ability and balance. The review also found that we still lack strong evidence for the effects of fitness training on quality of life, mood, and cognitive function. I also presented the current recommendations for exercise training after stroke, which include light walking and intermittent sitting and standing, seated activities and range-of-motion exercise as tolerated early after stroke. In subacute and chronic stroke, the recommendations include:
- CRF training: 55-80% HRmax [light to somewhat hard], 3-5 days/week, 20-60 min/session [can break up into 10 min bouts];
- Muscle strengthening: 1–3 sets, 10–15 repetitions, 8–10 exercises (major muscle groups), 50%–80% of your maximal effort, 2–3 d/week; and
- Flexibility and neuromuscular exercises (i.e. balance training).
I also discussed some of the current challenges in exercise rehabilitation after stroke in furthering our understanding of when exercise training should begin, what the optimal prescription might be, how to individualize training for a diverse group of patients, and then how to progress training.
Wayne followed with a presentation centred on how clinicians, like himself, can engage in research to improve their clinical practice. He also identified significant challenges in clinical practice that are potentially limiting implementation of the evidence, including:
- the risk averse nature of hospitals and health service providers
- limits on staff time and resources, and
- the challenge of working with survivors with severe impairments.
Importantly, Wayne used his research and clinical expertise to demonstrate how these barriers can be overcome. This included discussing evidence that demonstrates stroke survivors can safely exercise at a relatively high intensity, and that circuit classes, which can optimize staff time and resources, are efficacious post-stroke. He also presented several examples of specialized exercise equipment, such as the recumbent stepper, that can be used to enable all survivors to exercise regardless of level of impairment.
Establishing exercise training as a routine part of early stroke rehabilitation remains a challenge. Further research to unpack the optimal prescription and when exercise training should begin after stroke, which our research team is leading, will ultimately drive change in this space. To further facilitate translation we need to increase the presence of exercise physiologists within the acute allied health team, and promote their collaboration across the team, talk to stroke survivors about ‘sitting less, and moving more’, and increase access to adaptive exercise equipment.