GSS cIRcle Open Scholar Award (UBCV Non-Thesis Graduate Work)

The Effects of Aerobic Exercise on Functional Recovery Post Stroke As Defined by the ICF: Systematic.. Boersma, Heather; Evans, Hayley; Fraser, Christal; Ng, Elizabeth; Shapcotte, Erin 2008-08-21

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The Effects of Aerobic Exercise on Functional Recovery Post Stroke As Defined by the ICF:A Systematic ReviewHeather Boersma, Hayley Evans, ChristalFraser, Elizabeth Ng, J. Erin ShapcotteOutline ??Background information on stroke, aerobic exercise, aerobic capacity and function??Methods??Results??Discussion??Review Limitations and research recommendations??Clinical message??AcknowledgementsBackgroundStroke  ??Stroke is the number one cause of long-term adult disability??Total number of stroke survivors is increasing??60% of stroke survivors have residual motor impairments that may limit physical activity??Deconditioningcompromises physical independence and quality of life ??High risk of recurrent stroke and coronary artery diseaseAerobic Capacity ??Aerobic capacity is the body?s ability to deliver and utilize O2??Decreased physical activity severely decreases aerobic capacity??Stroke survivors have a 30-40% lower aerobic capacity than age-matched individualsAerobic Capacity and Function ??Stroke survivors have to work at a higher relative intensity compared to individuals with a higher VO2maxto complete the same functional tasks ??Increased energy demands secondary to stroke related deficits??Low aerobic capacity + increased energy demands = decreased functional capacityAerobic Exercise & Stroke??Aerobic exercise training increases aerobic capacity in the stroke population??Using a variety of exercise modalities??Results?able to perform the same activities at a lower sub-max VO2??Aerobic exercise reduces secondary disease and decreases the risk of recurrent strokeInternational Classification of Function, Disability and Health ??Provides a framework in which to categorize the collection of problems associated with stroke??Includes three domains: Body Function and Structure, Activity and Participation??Impairments??Activity limitations??Participation restrictionsResearch at the Impairment Level of the ICF??A meta-analysis on the effects of aerobic exercise training on aerobic capacity in individuals with stroke??Conclusions:??Aerobic exercise is effective at improving aerobic capacity in individuals with mild and moderate stroke??Provides support that aerobic exercise leads to improved function at the Impairmentlevel of the ICF Research at the Activity and Participation levels of the ICF ??The effect physical therapy interventions on function post stroke, including aerobic exercise??No improvements in ADL?sor IADL?s??Systematic review of exercise trials post stroke??Did not isolate aerobic exercise from functional exercise??Insufficient evidence to support cardiovascular interventions at increasing function Rationale for the Review ??Aerobic exercise has shown to be effective at treating deficits at the impairmentlevel ??The effectiveness of aerobic exercise inincreasing function at the activityand participationlevels remains unclear ??Important for clinicians to use literature supported treatment interventions??Taken together, a review of the relationship between aerobic exercise and function is warrantedSystematic Review Objective ??The objective of this systematic review isto determine if aerobic exercise improves function at the activity and participation levels of the ICF??Provide clinicians with the evidence to achieve best practice.MethodsReview question ??Does aerobic exercise improve functional ability in individuals recovering from stroke???Aerobic exercise defined by ACSM??20 -60 minutes ??3-5 days a week at 60% -80% HRmaxor 40%-60% HRR??Minimum of 6 weeks??Function defined by the ICFInclusion Criteria ??Clinical Trials on the effects of aerobic exercise training in individuals 19 years and older with stroke??Met the ACSM guidelines for aerobic exercise, or explicitly stated the use of an aerobic exercise intervention ??English full-text version could be obtained??At least one functional outcome measureExclusion Criteria ??Non peer-reviewed sources??Studies with multiple exercise interventions in which aerobic exercise cannot be isolatedLiterature Search??MEDLINE, EMBASE,CINAHL, SPORTdiscus, Cochrane Library Database of Systematic Reviews, PEDro??Completed in August 2007??Articles screened at title, abstract and full text??Completed by 2 independent reviewers (3rdreviewer for discrepancies) ??Reference lists of chosen articles were manually searched ??Web of Science to locate studies that referenced the chosen articlesQualitative Assessment ??PEDroscale was used to evaluate each article by 2 independent reviewers (3rd reviewer for discrepancies)??To assess the methodological quality of physical therapy RCT?s??All included RCTs were ?good???Grading??9-10: excellent??6-8: good??4-5: fair??<4: poorQuantitative analysis ??For each outcome measure the mean change scoreswere calculated??Baseline SD?s in the experimental and control groups were used to calculated the pooled population SD??Using RevMan,  SESwas calculated??Cohen?s classification ??Small: d=0.2??Medium: d=0.5??Large: d=0.8??95% CI calculated??Forest plots used for graphical representationResultsArticle Selection3133Combined resultsfollowing online database search-2830Rejected based on title alone303  Assessed at abstract level23Retained for analysis at full text level-18Excluded from further review5   Retained + 1Following Web of Science and manual search6  Studies based on 5 RCT?sSubjects??Number of subjects within each study ranged from 13-92 ??Calculated mean age: ~ 63 years old??Both sub-acute and chronic stroke survivors??Stroke impairment levels ranged from mild to moderate ??Only 3 RCT?sidentified stroke type??Ischemic, hemorrhagicExercise Training ProtocolAs per ACSM Guidelines??Cycle ergometerin conjunction with ?regular?physical therapy??Treadmill training??Treadmill training combined with Bobaththerapy??Water-based exercise (chest-deep water)Total intervention lengths:6 weeks, 8 weeks, 10 weeks, and 6 monthsOutcome Measures:Activity Level??WALKING VELOCITY:??10m walk, 8m walk, 30 foot self-paced walk??WALKING CAPACITY:??6 Minute Walk Test??BALANCE:??Berg Balance Scale, component of Fugl-Meyer Assessment??FUNCTIONAL MOBILITY:??RivermeadMobility Index??Gross Motor subscale of RivermeadMotor Assessment ScaleOutcome Measures:Activity and Participation Levels??FrenchayActivity Index??Functional Independence MeasureEffect of Treadmill Training ??2 studies used 6MWT and walking velocity (Eichet al. , Mackoet al.)??6MWT:??Used as a measure of walking capacity??Significant effect sizes (ES) found in favor of the exercise group??large effects:??d= 0.89 (Eichet al.) ??d=2.4 (Mackoet al.)Results ??Walking velocity:??Only Eichet al. found significant effects??Large: d= 0.98??Mackoet al. did not find significant effects??Trend toward favoring the exercise group??d= 0.43; CI -0.08-0.94 ??RivermeadMotor Assessment Scale (RMA)??No significant effect found (Eichet al.)??RivermeadMobility Index (RMI)??Large significant effect size found (Mackoet al.)??d= 2.42Treadmill Training Effect of Treadmill Training on Functional Outcomes-3.5-2.5-1.5- Mean DifferenceRMA (Eich, 2004) Walking Velocity (Macko, 2005) Walking Velocity (Eich, 2004) 6MWT (Eich, 2004) 6MWT (Macko, 2005) RMI (Macko, 2005)Favor ControlFavor ExperimentalEffects of Cycle ErgometerTraining  ??2 studies used this mode of training (Katz-Leurer, Potempa)??Outcome measures included the Functional independence measure (FIM), FrenchayActivities Index (FAI), and Fugl-Meyer Index??No significant effect sizes were producedCycle ErgometerEffect of Cycle Ergometer Training on Functional Outcomes-2-1.5-1-0.500.511.52Standard Mean DifferenceFugl-Meyer (Potempa) FIM (Katz-Leurer) FAI (Katz-Leurer)Favor ControlFavor ExperimentalWater-based aerobic exercise training ??One study used this mode of training (Chu et al.)??Measured the effects on balance and walking velocity??Balance (Berg Balance Score)??Significant effect size favoring the control group (d= 0.71)??Walking Velocity??No significant effect size foundWater based aerobic exerciseEffect of Water Based Aerobic Exercise on Functional Outcomes-2-1012Standard Mean DifferenceWalking Velocity, m/s (Chu et al., 2004) BBS (Chu et al., 2004)Favor ControlFavor ExperimentalAmbulation Categories ??Gait velocity can be divided into three functional ambulation categories: ??Household ambulation (<0.4 m/s) ??Limited community ambulation (0.4 to 0.8 m/s)??Full community ambulation (>0.8 m/s)Ambulation Categories ??Both Eichet al. and Mackoet al. investigated walking capacity  ??Eichet al. ??All participants were at the level of household ambulation ??Both groups progressed to limited community ambulation ??Treatment group had statistically significant changes in walking velocity ??No clinical significance was found between the two groups according to their ambulatory categoryAmbulation Categories ??Mackoet al.??Both treatment and control participants classified as limited community ambulators??Both did not progress to full community ambulation after study completion ??Small improvements were seen within the category??These results were consistent regardless of distance??Chu et al.??Treatment and control groups of study were at the level of full community ambulation at baseline ??Remained in this category after treatmentBody Structure/ FunctionActivityParticipation-no measuresWalking Capacity (6MWT)?significantly improved with treadmill trainingWalking Velocity?mixed results according to two studiesRMI ?significantly improved by treadmill training according to one study RMA, FIM, Fugl-Meyer ?No significant effect sizes produced with any mode of training Berg Balance Score?water based aerobic exercise does not help with balanceFAI, Fugl-Meyer?no significant improvements with aerobic cycle ergometertrainingDiscussionTreadmill Training??Improved walking capacity, and demonstrated a trend toward improved velocity and functional mobility??Evidence supports task-specific treadmill training in improving walking speed and walking capacity ??Capacity and velocity improvements could be due to:??practice specificity ??changes in aerobic capacity. Treadmill Training cont. ??RMI indicated improved functional mobility with AEX  ??Longer length intervention does not result in superior outcomes??In both studies statistically significant changes were found, did not result in clinically significant in ambulation categoryWater based Exercise ??AEX showed a trend towards improved walking velocity??All participants were considered full community ambulatorsat the onset of the study??Therefore there may have been a ceiling effect Cycle Ergometry ??Does not improve functional performance as measured by the Fugl-Meyer, FAI, and FIM scales??FIM and Fugl-Meyer have a ceiling effect when used to assess those with mild to  moderate stroke??The FAI has poor test-retest reliability which may account for the lack of observed change Review Limitations and Research RecommendationsRCT Limitations ??Small sample size ??Participants tended to be healthier and  less physically affected??Studies lacked long term follow-up. ??Type of stroke varied among studies. SR Limitations ??Only included studies utilizing the ACSM aerobic exercise guidelines ??Lower intensities may improve cardiovascular fitness in individuals with stroke??ACSM aerobic exercise guidelines were not used or measured in a # or treadmill training studies and therefore were excluded ??Lastly, variability among control interventions may have impacted inter-group comparisons and thus the results of this review. Literature Recommendations ??Future studies should use:??Larger sample sizes??Valid, reliable, and sensitive outcome measures that encompass all components of the ICF??Less task-specific interventions to determine the relationship between aerobic exercise and functional recovery ??Studies should also investigate whether ACSM guidelines are required to induce an aerobic training effect in the stroke populationClinical Message??Insufficient evidence to support aerobic exercise as a sole treatment intervention to enhance function. ??Aerobic exercise should remain one component of a comprehensive stroke rehabilitation program Conclusion ??Aerobic exercise does not appear to enhance functional parameters such as balance, or increase aspects of participation such as social outings, work, and hobbies as measured by FIM and FAI??Treadmill aerobic exercise increases walking capacity. 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