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Cardiac Rehabilitation for Strok

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					Cardiac Rehabilitation
for Stroke Patients

Dina Brooks,
Associate Professor
University of Toronto
Is it really survival
of the fittest?
               Why study stroke?


   Leading cause of neurological disability in
    adults
   40,000 – 50,000 strokes per year
   300,000 stroke survivors in Canada
   60% have functional impairments
          Physical impairments

 Weakness
 Reduced range of motion
 Sensory changes
 Altered muscle tone
 Impaired coordination
 Reduced exercise capacity/fitness level
          Impact of reduced fitness


   Activities of Daily Living
   Altered walking
     2/3 of stroke survivors have impaired
      walking function
     1/2 of stroke survivors are unable to
      walk at all
           Functional ambulation

The capacity to execute safe, efficient walking within time
and environmental constraints encountered in everyday
life


     Sensorimotor                      Fitness
        Control




               Functional Ambulation
           Implications for function

 Cardiorespiratory and walking deficits may
 mutually reinforce one another


                          Impaired
                           walking
                                            Limits activity
 mechanical efficiency
                                          Sedentary lifestyle
    metabolic costs
                                          Further weakness


                          Reduced
                  cardiorespiratory fitness
                 In addition…..


   75% with history of heart disease

   50 - 84% have high blood pressure

   40% have severe coronary artery disease
                Stroke risk factors


 Hypertension           Atrial fibrillation
 Smoking                High cholesterol
 Diabetes               Obesity
 Carotid stenosis       Physical Inactivity


Risk of second stroke or heart attack
                Cardiovascular event

Stroke Rehab                Cardiac Rehab
-? 1-2 months               -Up to 12 months
-Functional recovery        -Supervised exercise program
-Little exercise training   -Education
-Little formal education    -Nutritional Support
          Fitness in stroke:
     What does the literature say?

 Exercise program feasible in stroke
 Results in:
     o   improved fitness level
     o   reduced neurological impairment
     o   enhanced lower extremity function
 Changes in fitness levels from 8 to 23%
 Not uniform effect throughout the groups
          Fitness in stroke:
     What does the literature say?

 Studies focus on exercise exclusively
 Generally less than three months


Why not use an established and common
 model of care (cardiac rehabilitation) and
 apply to the stroke population?
        Cardiac rehabilitation model


Cardiac Rehab
     Up to 12 months
     Supervised exercise program
     Education
     Nutritional Support
  Effects of Cardiac Rehabilitation for
      Individuals Following Stroke



Heart & Stroke Foundation of Ontario
    Stroke Rehabilitation Special
      Competition #SRA 5977
                        Purpose


   Establish feasibility of cardiac rehabilitation
    for individuals with stroke
   Determine the effects on:
     Exercise, walking capacity and ability
     Community re-integration
     Quality of life
     Risk factors for subsequent stroke
                          Design


Test 1               Test 2           Test 3      Test 4

         Baseline             Cardiac Rehab program
          3 months                   6 months
                          Outcomes
   Maximal exercise test
     Semi-recumbent cycle
      ergometry
     VO2peak
      Peak Work Rate
      Peak Heart Rate
   6-Minute Walk Test (6MWT)
   Stroke Impact Scale (SIS)
   Risk factor profile
   Community reintegration
        Intervention – Cardiac Rehab

   Aerobic training 4-5 days / week
    Resistance training 2 days / week
   Education sessions
   Training once a week at Centre
   Exercise diary
       Progress to date – Research

   53 people have been recruited for the study
   10 people were not entered, leaving 43
    participants who enrolled into the study.
   17 were able to walk without use of gait aids,
    18 used a single point cane, 1 used a quad
    cane and 7 used a walker or rollator.
                 Preliminary results
                 Participant Demographics - All
                     n=43 completed Baseline testing


Men / Women                                   30 / 13
Age                                           64 ± 13 (38-86)
Months post stroke                            30 ± 28 (3-120)
Type: Isch / Hemorr / Unknown                 28 / 10 / 5

R / L / Bilat hemisphere affected             16 / 25 / 2
                 Preliminary results
 Changes during 3-month baseline period
                         (n=34)


                   0 months       3 months     p
VO2peak, mlkg-    13.1 ± 4.8     14.9 ± 5.5   NS
1min-1

Peak work rate,    59.9 ± 30      61.3 ± 33    NS
watts
Peak heart rate,   110.8 ± 21     116 ± 23     NS
beats/min
6-Minute Walk      267.9 ±        273.9 ±      NS
Test distance,     135            122
              Preliminary results
  Changes following program completion
                        (n=27)


                     0 months      3 months
VO2peak, mlkg-      14.9 ± 5.5    16.6 ± 5.5
1min-1

Peak work rate,      61.3 ± 33     61.6 ± 31.9
watts
Peak heart rate,     116 ± 23      114 ± 23
beats/min
6-Minute Walk Test   273.9 ± 132   299.4 ± 145.8
distance,
              Preliminary results

   No change in function during baseline 3
    months
   Attended 85% of scheduled classes
   14% improvement in fitness level
   9% reductions in BP
   10% greater walking ability
   6% lower relative stroke risk
               Preliminary results

   Subjects extremely satisfied with the
    program and wish to continue
   Adaptation required for the program
   Partners satisfied and wish to participate
                       Discussion
   Aerobic and functional capacity in this population is low.
   In the absence of formal community-based exercise,
    these measures remain unchanged.
   Preliminary results suggest positive benefit to
    cardiorespiratory fitness, blood pressure and lower stroke
    risk
   Ongoing data collection
How this research addresses the gap in
             stroke care?
   Present rehab programs for Stroke
        ? 1-2 months
        Functional recovery
        Little exercise training
        Little formal education
   That is not enough!
          Impact on the community


   It is time that we start using an
    established and common model of care
    (cardiac rehabilitation) in individuals with
    stroke
                Key messages


 Fitness levels very low in stroke patients
 Rehabilitation should include a formal
  exercise component
 Cardiac rehabilitation can be adapted for
  patients with stroke
AND WE WILL CHANGE PRACTICE!
                Acknowledgements


   Toronto Rehabilitation Institute Neuro Rehab and Cardiac
    Rehab Programs for their ongoing support and assistance
          Research Team
      William McIlroy and Dina Brooks

Scott Thomas              Ada Tang
Mark Bayley               Kathryn Sibley
Paul Oh                   Valerie Closson
Sandra Black              Cynthia Danells
Jim Salhas                Hannah Cheung
                 Thank you!

Questions, comments…

  Dina Brooks PhD
    dina.brooks@utoronto.ca
Fitness in Community for Chronic Stroke
                         Purpose


   To determine the proportion of fitness facilities in
    the Greater Toronto Area (GTA) that provide
    programs specifically developed for stroke
    survivors.
   To identify the components and resources utilized
    by stroke specific fitness programs.
   To determine perceived and actual barriers to
    offering fitness programs for stroke survivors.
                   Methods


 Cross-sectional descriptive study
 Questionnaire was distributed to 784
  fitness facilities in the GTA asking
                    Results


 Of 213 respondents, 146 facilities reported
  that individuals with a chronic disability
  participated
 62 facilities offered specific fitness
  programs for individuals with a chronic
  disability
 26 with stroke-specific fitness programs
                   Findings


 Typical stroke fitness programs operated
  as not-for-profit organizations, in large
  facilities
 Specific acceptance criteria for stroke
  survivors to participate
 Stroke-specific programs included aerobic,
  flexibility training and strengthening.

				
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posted:10/27/2010
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