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The Effects of Aerobic Exercise on Activities of Daily Living Post Stroke Boeckermann-Belanger, Leah; Dulong, Jessica; Gilbert, Kendra; McColl, Jeanine; Whyte, Allison; Wilson, Meredith 2009

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The Effects of Aerobic Exercise on Activities of Daily Living Post StrokePresented by:Leah Boeckermann-BelangerJessica DulongKendra GilbertJeanine McColl  Allison WhyteMeredith WilsonOutlineIntroductionMethodsResultsDiscussionParticipantsInterventionsControlOutcomeConclusionClinical ImplicationsBackgroundStroke, a blockage or bleed     in the brain, represents one 	of the leading causes 	of morbidity in Canada1Resultant signs & symptoms can have a negative impact on one’s ability to live their daily life1Stroke places a large economic burden ($2.8 billion) on the Canadian Health Care System1Background: Aerobic ConditioningModerate intensity aerobic exercise has been shown to  risk of stroke in a dose response manner2Post stroke, individuals exhibit an extensive  in aerobic conditioning, resulting from the event &  subsequent  in physical activity3,4 aerobic fitness combined with  energy demands greatly affects ability to perform ADLs5,6Background: VO2Treadmill training  energy expenditure & CV demands of gait in individuals with stroke6,7VO2max of at least 15ml/kg/min for women & 18 ml/kg/min for men is required for independent living8Individuals with stroke who participated in an aerobic program had an average  in VO2max of 13% compared to control3 aerobic fitness has been associated with functional gains including  mobility,  falls, &  ability to carry out ADLs9Background: Neuroprotective Effect and NeuroplasticityAerobic exercise has a neuroprotective effect on the brainBrain derived neurotrophic factor appears to be most sensitive to regulation via exerciseIt may be of importance in mediating the benefits of exercise on neural plasticity & the benefits of exercise on CNS healthImportant post stroke as neuroplasticity is required in order for neural reorganization & regeneration to occur, resulting in  function of the individual10Why is it relevant to Physical Therapists?To assist in making clinical decisions regarding effectiveness of aerobic training in individuals post stroke, thus ensuring that limited therapy resources are being used effectivelyTo determine the type, duration & intensity of aerobic activity that is most beneficial for those affected by strokeResearch QuestionWhat is the effect of aerobic exercise training on the ADLs in individuals with stroke?MethodsInclusion criteria:English RCTsIndividuals with stroke who are medically stable & capable of performing aerobic exerciseAerobic intervention, min 3x/wk, at least 4 wks3Reliable & valid outcome measure (OM)12-24MethodsExclusion Criteria:Participants involved in aerobic activity prior to study onsetCombination of training (e.g. aerobic + strength training)Methods: Search StrategySept 2008 - Jan 2009CINAHL, EMBASE, MEDLINE, Unindexed MEDLINE, SportDiscusTitles, abstracts, full text, & hand-searching screened by 2 independent reviewersDiscrepancies resolved by discussion or 3rd reviewerMethods: Quality Assessment & Data AbstractionPEDro Methodological Quality Assessment ScaleData Abstraction form2 independent reviewersDiscrepancies resolved by discussion or 3rd reviewerData AnalysisDue to heterogeneous results qualitative analysis was performedSelected StudiesReasons for ExclusionMulti-modality interventionsLack of control groupLack of aerobic interventionInsufficient training frequency & durationLanguage other than EnglishAbsence of a reliable & valid OMResults: Study Details1 cycle ergometer, 3 treadmill, 1 gait trainerOM: Frenchay Activity Index (FAI), Nottingham, Stroke Impact Scale Domain 5 (SIS-5), Rivermead Mobility Index (RMI), Functional Independence Measure (FIM), Barthel Index (BI)Quality assessment scores: 5-9/ 11Results: Demographic InfoFirst AuthorParticipant mean ageInitial # of participants I:CFinal # of participants I:CCondition or Type of StrokeTime post-strokeKatz-Leurer 63 +/- 11 46 : 4646 : 44Hemorrhage, InfarctionNot specifiedListon 79.1 +/- 6.8 10 : 8                                        (Treadmill 1st: Conventional PT 1st)8 : 8                                                        (Treadmill 1st: Conventional PT 1st) Leukoaraiosis, Infarct,  Low Density Area, Leukoaraiosis, InfarctNot specifiedMacko  63 +/- 10                                                                                                                                                                                                      32 : 2925 : 20Ischemic> 6 monthsPohl  62.3 +/- 12   (range: 26 - 79)                                                                                                                                                                                                    77 : 7872 : 72 (After 4 weeks)Ischemic, Hemorrhagic     < 60 daysSmith 57.8                                                   (range: 42-72)10 : 1010 : 10Ischemic> 3 months,   < 2 yearsKatz-Leurer et al (2003)25-26Leg cycle ergometer trainingPart 1: 5 days/wk for 2 wks, up 	to 20 min continuousPart 2: 6 wks: 30min, 3x/wkIntensity: 60% HRRControl: regular therapy 5 days/ wkOM: FAI, FIMKatz-Leurer et al (2003)25,26  cont.FAI scores pre stroke & at 6 months follow-upTotal score  10 pts in both control & intervention groupsThose with more severe stroke showed greater improvementsTrend towards improvement in all parameters of functional ability in experimental group, but FIM showed no statistical differenceListon et al (2000)27Treadmill: walking as long as comfortable,	rest breaks as needed, up to 60min, 	3x/wk, 6 wksSelf selected intensityControl: conventional PTOM: NottinghamNo significant differences b/n the groupsMacko et al (2005)28Treadmill40 min walking, 3x/wk, 6 monthsStarted at 40-50% HRR for 10-20 min;  5% HRR every 2 wks;  5 min every 2 wks (as tolerated)Control40 min stretching & low-intensity treadmill walking 3x/wk for 6 monthsOM: RMINo statistically significant difference b/n groupsPohl et al (2007)29Gait trainer:Up to 20 min + 25 min 	conventional PT, 5x/wk, 4 wksProgressed by  body wt supportControl:45 min conventional PTOM: BI, RMIPohl et al (2007)29 cont.BI: significant difference in favour of intervention group (chi-squared test p<0.0125)RMI: intervention significantly better than control (p<0.0001)Smith (2006)30Treadmill:12 sessions over 4 wks, 20 min walking with unlimited rest breaks 0.2mph once achieved 10 min continuous at self selected velocity; <13 on 20 point Borg scaleControl: QOL logsOM: SIS - Domain 5Trend towards  ADL function in experimental group, not statistically significantResults: % Change Over TimeResultsBased on the 5 data sets in this systematic review, no patterns of improvement in ADLs were foundDiscussion: ParticipantsHigh variability among the participants, particularly stroke severity, likely contributed to lack of significanceThe participants in the Pohl29 study had more severe functional deficits (non-ambulatory or required assistance) & it was the only study that had significant findingsKatz-Leurer25,26 found an interaction effect b/n event severity, FAI, & intervention in favour of those more severely affectedDiscussion: Participants cont.More severely affected participants likely had lower VO2max due to deconditioning post stroke & thus had more to gain from an aerobic intervention3,4Therefore, aerobic activity is likely important in   ADL function in those with greater functional deficitsAdditional research is neededDiscussion: Participants cont.Participants also differed in type & location of stroke & time since strokeDamage to different areas of the brain may result in altered abilities to recover31Individuals entering rehab earlier post stroke have a larger window for recovery32Pohl et al29 accepted individuals who were <60 days post stroke & this was the only study to show improvements in ADLsSpontaneous recovery Discussion: Participants cont.Small sample sizes may have contributed to the lack of significant findings & thus larger sample sizes are requiredPohl et al29, with the largest sample size at 72 participants per group,  was the only study to show significant results Discussion: InterventionHeterogeneity of exercise dose is the most prominent issue impacting outcomesDuration:ACSM: 15-20 wk length intervention may be an adequate min standard for healthy populations to assess effectiveness of various doses of aerobic exercise11We suggest that the length of intervention should meet this criteria as this is the most evidence based guideline availableDiscussion: Intervention cont.Macko et al28 had the longest study period, however had no significant findingsThis may be due to the use of the RMI, a dichotomous scale relating specifically to mobilityBecause participants were ambulatory at study start, they may have reached a ceiling effectPohl et al29 used the same OM, but with initially non-ambulatory participantsLess likely to reach same ceiling effectDiscussion: Intervention cont.Intensity:ACSM: to achieve cardiorespiratory benefits from training, an intensity of 40/50-85% HRR is required in healthy individuals342 studies used HRR to measure intensity25,26,28, 1 used the Borg RPE29, & others did not report intensity27,30Unable to determine if intensity was sufficient in all studies to produce a training effect according to the ACSM guidelines for healthy individualsDiscussion: Intervention cont.Rest Breaks:Liston et al27 & Smith30 allowed unlimited rest breaks for the participants - number & duration were not documentedA minimum of 10 mins of continuous aerobic exercise is required in healthy individuals for a training effect34Unable to determine if 10 mins of continuous aerobic activity was achieved in these studiesDiscussion: ControlsLarge variability in control group therapy3 of the control groups participated in walking however at a lower dose than the experimental group27,28,29Due to similar interventions the ability to detect change between groups may have been confoundedDiscussion: Controls cont.Smith30 found a trend in favour of the intervention groupThe control group used only QOL logsIt is likely that a training stimulus may have improved ADLs in those studies that involved conventional PT in the control groupIt may be more pertinent to compare aerobic exercise to conventional PT in order to determine if aerobic exercise should be incorporated as part of a conventional PT programDiscussion: OutcomeSpecificityLimited specificity of studies with regards to the intervention & the ADL tasks being measured3 studies25-27,30 chose ADL measures that were not closely related to the intervention & all had insignificant findingsPohl et al29 used mobility related OM & demonstrated a statistically significant difference in favour of the intervention groupLimitations Lack of high quality primary evidenceBroad study question: heterogeneous QualitativeEnglish studies onlyAuthors were not contacted to retrieve unpublished dataConclusionAdequate dose must be achieved to see changes in ADLs in individuals post strokeHigher quality & more specific studies are required to determine a dose response relationship for aerobic exercise post stroke & to find patterns among studiesOMs must be specific to the interventionClinical ImplicationsLimited evidence suggests that aerobic exercise has positive effects on ADLs in non-ambulatory individuals post strokeAerobic exercise should be used in conjunction with conventional PT as there is limited evidence to support its use in improving ADLs in individuals post strokeIndividuals post stroke must persist with an aerobic exercise program to continue to see changes in ADL functionAcknowledgementsDarlene Reid & Elizabeth DeanCharlotte BeckLara BoydReferencesCanadian Brain and Nerve Health Coalition. The burden of neurological diseases, disorders, and injuries in canada. . 2007. Hu FB, Stampfer MJ, Colditz GA, et al. Physical activity and risk of stroke in women. J Am Med Assoc. 2000;283(22:ate of Pubaton: 14 Jun 2000. 3. 	Potempa K, Lopez M, Braun LT, Szidon JP, Fogg L, Tincknell T. Physiological outcomes of aerobic exercise training in hemiparetic stroke patients. Stroke. 1995;26:101-105. 4. 	Landin S, Hagenfeldt L, Saltin B, Wahren J. Muscle metabolism during exercise in hemiparetic patients. Clin Sci Mol Med. 1977;53:257-269. 5.	Ivey FM, Macko RF, Ryan AS, Hafer-Macko CE. Cardiovascular health and fitness after stroke. Topics in Stroke Rehabilitation. 2005;12:1-16. Macko RF, Smith GV, Dobrovolny CL, Sorkin JD, Goldberg AP, Silver KH. Treadmill training improves fitness reserve in chronic stroke patients. Arch Phys Med Rehabil. 2001;82:879-884. Silver KH, Macko RF, Forrester LW, Goldberg AP, Smith GV. Effects of aerobic treadmill training on gait velocity, cadence, and gait symmetry in chronic hemiparetic stroke: A preliminary report. Neurorehabil Neural Repair. 2000;14:65-71. 8.	Shephard RJ. Maximal oxygen intake and independence in old age. Br J Sports Med. 2009;43:342-346. Kalapotharakos VI, Michalopoulos M, Strimpakos N, Diamantopoulos KBS, Tokmakidis SP. Functional and neuromotor performance in older adults: Effect of 12 wks of aerobic exercise. American Journal of Physical Medicine & Rehabilitation. 2006;85:61-67. Vaynman S, Gomez-Pinilla F. License to run: Exercise impacts functional plasticity in the intact and injured central nervous system by using neurotrophins. Neurorehabil Neural Repair. 2005;19:283-295. Armstrong L, Balady GJ, Berry MJ, et al. ACSM's Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore Maryland: Lippincott Williams & Wilkins; 2006. de Bruin AF, de Witte LP, Stevens F, Diederiks JPM. Sickness impact profile: The state of the art of a generic functional status measure. Social Science and medicine. 1992 Oct;35:1003-1014. 13. 	Duncan PW, Wallace D, Lai SM, Johnson D, Embretson S, Laster LJ. The stroke impact scale version 2.0: Evaluation of reliability, validity, and sensitivity to change. Stroke. 1999 Oct;30:2131-2140. 14.	Hartigan I. A comparative review of the katz ADL and the barthel index in assessing the activities of daily living of older people. International Journal of Older People Nursing. 2007 September:204-212. 15.	Harwood RH, Ebrahim S. A comparison of the responsiveness of the nottingham extended activities of daily living scale, london handicap scale and SF-36. Disability & Rehabilitation. 2000 Nov;22:786-793. 16.	Loewen SC, Anderson BA. Reliability of the modified motor assessment scale and the barthel index. Physical Therapy. 1988 Jul;68:1077-1081. 17.	Parker CJ, Gladman JRF, Logan PA. Development and validation of the nottingham leisure questionnaire Clinical Rehabilitation. 2001 Dec;15:647-56.18. 	Rossier P, Wade DT, Murphy M. An initial investigation of the reliability of the rivermead extended ADL index in patients presenting with neurological impairment. Journal of Rehabilitation Medicine. 2001 Mar;33:61-70.19.	Salter K, Jutai JW, Teasell R, Foley NC, Bitensky J, Bayley M. Issues for selection of outcome measures in stroke rehabilitation: ICF activity. Disability & Rehabilitation. 2005 Mar;27:315-40. 20.	Schepers VPM, Ketelaar M, van de Port IGL, Visser-Meily JMA, Lindeman E. Comparing contents of functional outcome measures in stroke rehabilitation using the international classification of functioning, disability and health. Disability & Rehabilitation. 2007 February;29:221-230. 21.	Schlote A, Krüger J, Topp H, Wallesch C. Inter-rater reliability of the barthel index, the activity index, and the nottingham extended activities of daily living: The use of ADL instruments in stroke rehabilitation by medical and non medical personnel Rehabilitation. 2004 Apr;43:75-82. 22.	Streppel KRM, van Harten WH, Warmerdam CGM. Short version of the sickness impact profile for evaluating rehabilitation programs. Journal of Rehabilitation Sciences. 1996;9:66-71. 23.	Van de Port IGL, Ketelaar M, Schepers VPM, Van den Bos GAM, Lindeman E. Monitoring the functional health status of stroke patients: The value of the stroke-adapted sickness impact profile-30. Disability & Rehabilitation. 2004 Jun;26:635-640. Wilkinson PR, Wolfe CDA, Warburton FG, et al. Longer term quality of life and outcome in stroke patients: Is the barthel index alone an adequate measure of outcome? Quality in Health Care. 1997 Sept;6:125-130. 25.	Katz-Laurer M, Carmeli E, Shochina M. The effect of early aerobic training on independence six months post stroke. Clin Rehabil. 2003;17:735-741. 26.	Katz-Leurer M, Shochina M, Carmeli E, Friedlander Y. The influence of early aerobic training on the functional capacity in patients with cerebrovascular accident at the subacute stage. Arch Phys Med Rehabil. 2003;84:1609-1614.27.	Liston R, Mickelborough J, Harris B, Hann AW, Tallis RC. Conventional physiotherapy and treadmill re-training for higher-level gait disorders in cerebrovascular disease. Age & Ageing. 2000;29:311-318. 28.	Macko RF, Ivey FM, Forrester LW, et al. Treadmill exercise rehabilitation improves ambulatory function and cardiovascular fitness in patients with chronic stroke: A randomized, controlled trial. Stroke. 2005;36:2206-2211. 29.	Pohl M, Werner C, Holzgraefe M, et al. Repetitive locomotor training and physiotherapy improve walking and basic activities of daily living after stroke: A single-blind, randomized multicentre trial (DEutsche GAngtrainerStudie, DEGAS). Clin Rehabil. 2007;21:17-27. 30.	Smith PS. The effect of treadmill training on functional limitation and disability measures in persons in the chronic stage of recovery from stroke. Texas Woman's University; 2006. 31.	Chen C, Tang F, Chen H, Chung C, Wong M. Brain lesion size and location: Effects on motor recovery and functional outcome in stroke patients. Arch Phys Med Rehabil. 2000;81:447-452. 32.	Furlan M, Marchai G, Viader F, Derlon J-, Baron J-. Spontaneous neurological recovery after stroke and the fate of the ischemic penumbra. Ann Neurol. 1996;40(2:ate of Pubaton: Aug 1996. 33.	Rimmer JH, Rauworth AE, Wang EC, Nicola TL, Hill B. A preliminary study to examine the effects of aerobic and therapeutic (nonaerobic) exercise on cardiorespiratory fitness and coronary risk reduction in stroke survivors. Arch Phys Med Rehabil. 2009;90:407-412.  34.	Pollock MLPD, Facsm, Gaesser GAPD, F.A.C.S.M., et al. ACSM position stand: The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Medicine & Science in Sports & Exercise. 1998;30:975-991. Questions? Introduce that there were 6 studies found but only 5 independent data sets*Talk about 10 point decrease* The Effects of Aerobic Exercise on Activities of Daily Living Post Stroke Presented by: Leah Boeckermann-Belanger Jessica Dulong Kendra Gilbert Jeanine McColl Allison Whyte Meredith Wilson  Outline      Introduction Methods Results Discussion  Participants  Interventions  Control  Outcome   Conclusion  Clinical Implications  Background  Stroke, a blockage or bleed in the brain, represents one of the leading causes of morbidity in Canada1  Resultant signs & symptoms can have a negative impact on one’s ability to live their daily life1  Stroke places a large economic burden ($2.8 billion) on the Canadian Health Care System1  Background: Aerobic Conditioning  Moderate intensity aerobic exercise has been shown to ↓ risk of stroke in a dose response manner2  Post stroke, individuals exhibit an extensive ↓ in aerobic conditioning, resulting from the event & subsequent ↓ in physical activity3,4  ↓ aerobic fitness combined with ↑ energy demands greatly affects ability to perform ADLs5,6  Background: VO2  Treadmill training ↓ energy expenditure & CV demands of gait in individuals with stroke6,7  VO2max of at least 15ml/kg/min for women & 18 ml/kg/min for men is required for independent living8  Individuals with stroke who participated in an aerobic program had an average ↑ in VO2max of 13% compared to control3  ↑ aerobic fitness has been associated with functional gains including ↑ mobility, ↓ falls, & ↑ ability to carry out ADLs9  Background: Neuroprotective Effect and Neuroplasticity  Aerobic exercise has a neuroprotective effect on the brain  Brain derived neurotrophic factor appears to be most sensitive to regulation via exercise  It may be of importance in mediating the benefits of exercise on neural plasticity & the benefits of exercise on CNS health  Important post stroke as neuroplasticity is required in order for neural reorganization & regeneration to occur, resulting in ↑ function of the individual10  Why is it relevant to Physical Therapists?  To assist in making clinical decisions regarding effectiveness of aerobic training in individuals post stroke, thus ensuring that limited therapy resources are being used effectively  To determine the type, duration & intensity of aerobic activity that is most beneficial for those affected by stroke  Research Question  What is the effect of aerobic exercise training on the ADLs in individuals with stroke?  Methods  Inclusion criteria:  English RCTs  Individuals with stroke who are medically stable & capable of performing aerobic exercise  Aerobic intervention, min 3x/wk, at least 4 wks3  Reliable & valid outcome measure (OM)12-24  Methods  Exclusion Criteria:  Participants involved in aerobic activity prior to study onset  Combination of training (e.g. aerobic + strength training)  Methods: Search Strategy  Sept 2008 - Jan 2009  CINAHL, EMBASE, MEDLINE, Unindexed MEDLINE, SportDiscus  Titles, abstracts, full text, & hand-searching screened by 2 independent reviewers  Discrepancies resolved by discussion or 3rd reviewer  Methods: Quality Assessment & Data Abstraction  PEDro Methodological Quality Assessment Scale  Data Abstraction form  2 independent reviewers  Discrepancies resolved by discussion or 3rd reviewer  Data Analysis  Due to heterogeneous results qualitative analysis was performed  Selected Studies Initial Search 1069 Excluded after title screen 880  Included after title screen 189  Excluded after de-duplication 46  Included after de-duplication 143  Excluded after abstract screen 103  Included after abstract screen 40  Excluded after full text screen 36  Included after full text screen 4  Handsearching occurred 3 Included after handsearching 7 Included after MS study removed 6  Reasons for Exclusion        Multi-modality interventions Lack of control group Lack of aerobic intervention Insufficient training frequency & duration Language other than English Absence of a reliable & valid OM  Results: Study Details  1 cycle ergometer, 3 treadmill, 1 gait trainer  OM: Frenchay Activity Index (FAI), Nottingham, Stroke Impact Scale Domain 5 (SIS-5), Rivermead Mobility Index (RMI), Functional Independence Measure (FIM), Barthel Index (BI)  Quality assessment scores: 5-9/ 11  Results: Demographic Info First Author Katz-Leurer  Participant mean age 63 +/- 11  Initial # of participants I:C 46 : 46  Final # of participants I:C 46 : 44  Liston  79.1 +/- 6.8  10 : 8  8:8  Macko  63 +/- 10  (Treadmill 1st: Conventional PT 1st) 32 : 29  (Treadmill 1st: Conventional PT 1st) 25 : 20  Pohl  62.3 +/- 12 (range: 26 - 79)  77 : 78  72 : 72 (After 4 weeks)  Condition or Type of Time postStroke stroke Hemorrhage, Not specified Infarction Leukoaraiosis, Not specified Infarct, Low Density Area, Leukoaraiosis, Infarct Ischemic  > 6 months  Ischemic, Hemorrhagic  < 60 days  Katz-Leurer et al (2003)25-26  Leg cycle ergometer training  Part 1: 5 days/wk for 2 wks, up  to 20 min continuous  Part 2: 6 wks: 30min, 3x/wk  Intensity: 60% HRR   Control: regular therapy 5 days/ wk  OM: FAI, FIM  Katz-Leurer et al (2003)25,26 cont.  FAI scores pre stroke & at 6 months follow-up  Total score ↓ 10 pts in both control & intervention groups  Those with more severe stroke showed greater improvements  Trend towards improvement in all parameters of functional ability in experimental group, but FIM showed no statistical difference  Liston et al (2000)  27   Treadmill:  walking as long as comfortable, rest breaks as needed, up to 60min, 3x/wk, 6 wks  Self selected intensity   Control: conventional PT  OM: Nottingham  No significant differences b/n the groups  Macko et al (2005)28  Treadmill  40 min walking, 3x/wk, 6 months  Started at 40-50% HRR for 10-20 min; ↑ 5% HRR every 2 wks; ↑ 5 min every 2 wks (as tolerated)   Control  40 min stretching & low-intensity treadmill walking 3x/wk for 6 months   OM: RMI  No statistically significant difference b/n groups  Pohl et al (2007)29  Gait trainer:  Up to 20 min + 25 min  conventional PT, 5x/wk, 4 wks  Progressed by ↓ body wt support   Control:  45 min conventional PT   OM: BI, RMI  Pohl et al (2007)29 cont.  BI: significant difference in favour of intervention group (chi-squared test p<0.0125)  RMI: intervention significantly better than control (p<0.0001)  Smith (2006)30  Treadmill:  12 sessions over 4 wks, 20 min walking with unlimited rest breaks  ↑ 0.2mph once achieved 10 min continuous at self selected velocity; <13 on 20 point Borg scale   Control: QOL logs  OM: SIS - Domain 5  Trend towards ↑ ADL function in experimental group, not statistically significant  Results: % Change Over Time Control % change (finalinitial)  175  155  Experimental % change (finalinitial)  135  Control % change at follow up (from initial)  % change  115  95  Experimental % change at follow up (from initial)  75  55  Control % change at follow up (from final)  35  15  -5  Katz-Leurer - FIM  Smith - SIS  Liston - Nottingham  Macko -RMI Study  Pohl - BI  Pohl - RMI  Experimental % change from follow up (from final)  Results  Based on the 5 data sets in this systematic review, no patterns of improvement in ADLs were found  Discussion: Participants  High variability among the participants, particularly stroke severity, likely contributed to lack of significance  The participants in the Pohl29 study had more severe functional deficits (non-ambulatory or required assistance) & it was the only study that had significant findings  Katz-Leurer25,26 found an interaction effect b/n event severity, FAI, & intervention in favour of those more severely affected  Discussion: Participants cont.  More severely affected participants likely had lower VO2max due to deconditioning post stroke & thus had more to gain from an aerobic intervention3,4  Therefore, aerobic activity is likely important in ↑ ADL function in those with greater functional deficits  Additional research is needed  Discussion: Participants cont.  Participants also differed in type & location of stroke & time since stroke  Damage to different areas of the brain may result in altered abilities to recover31  Individuals entering rehab earlier post stroke have a larger window for recovery32  Pohl et al29 accepted individuals who were <60 days post stroke & this was the only study to show improvements in ADLs  Spontaneous recovery  Discussion: Participants cont.  Small sample sizes may have contributed to the lack of significant findings & thus larger sample sizes are required  Pohl et al29, with the largest sample size at 72 participants per group, was the only study to show significant results  Discussion: Intervention  Heterogeneity of exercise dose is the most prominent issue impacting outcomes Duration:  ACSM: 15-20 wk length intervention may be an adequate min standard for healthy populations to assess effectiveness of various doses of aerobic exercise11  We suggest that the length of intervention should meet this criteria as this is the most evidence based guideline available  Discussion: Intervention cont.  Macko et al28 had the longest study period, however had no significant findings  This may be due to the use of the RMI, a dichotomous scale relating specifically to mobility  Because participants were ambulatory at study start, they may have reached a ceiling effect   Pohl et al29 used the same OM, but with initially non-ambulatory participants  Less likely to reach same ceiling effect  Discussion: Intervention cont. Intensity:  ACSM: to achieve cardiorespiratory benefits from training, an intensity of 40/50-85% HRR is required in healthy individuals34  2 studies used HRR to measure intensity25,26,28, 1 used the Borg RPE29, & others did not report intensity27,30  Unable to determine if intensity was sufficient in all studies to produce a training effect according to the ACSM guidelines for healthy individuals  Discussion: Intervention cont. Rest Breaks:  Liston et al27 & Smith30 allowed unlimited rest breaks for the participants - number & duration were not documented  A minimum of 10 mins of continuous aerobic exercise is required in healthy individuals for a training effect34  Unable to determine if 10 mins of continuous aerobic activity was achieved in these studies  Discussion: Controls  Large variability in control group therapy  3 of the control groups participated in walking however at a lower dose than the experimental group27,28,29  Due to similar interventions the ability to detect change between groups may have been confounded  Discussion: Controls cont.  Smith30 found a trend in favour of the intervention group  The control group used only QOL logs   It is likely that a training stimulus may have improved ADLs in those studies that involved conventional PT in the control group  It may be more pertinent to compare aerobic exercise to conventional PT in order to determine if aerobic exercise should be incorporated as part of a conventional PT program  Discussion: Outcome Specificity  Limited specificity of studies with regards to the intervention & the ADL tasks being measured  3 studies25-27,30 chose ADL measures that were not closely related to the intervention & all had insignificant findings  Pohl et al29 used mobility related OM & demonstrated a statistically significant difference in favour of the intervention group  Limitations       Lack of high quality primary evidence Broad study question: heterogeneous Qualitative English studies only Authors were not contacted to retrieve unpublished data  Conclusion  Adequate dose must be achieved to see changes in ADLs in individuals post stroke  Higher quality & more specific studies are required to determine a dose response relationship for aerobic exercise post stroke & to find patterns among studies  OMs must be specific to the intervention  Clinical Implications  Limited evidence suggests that aerobic exercise has positive effects on ADLs in non-ambulatory individuals post stroke  Aerobic exercise should be used in conjunction with conventional PT as there is limited evidence to support its use in improving ADLs in individuals post stroke  Individuals post stroke must persist with an aerobic exercise program to continue to see changes in ADL function  Acknowledgements  Darlene Reid & Elizabeth Dean  Charlotte Beck  Lara Boyd  References 1. 2. 3. 4. 5. 1. 2. 8. 1. 2. 3. 4.  Canadian Brain and Nerve Health Coalition. The burden of neurological diseases, disorders, and injuries in canada. . 2007. Hu FB, Stampfer MJ, Colditz GA, et al. Physical activity and risk of stroke in women. J Am Med Assoc. 2000;283(22:ate of Pubaton: 14 Jun 2000. Potempa K, Lopez M, Braun LT, Szidon JP, Fogg L, Tincknell T. Physiological outcomes of aerobic exercise training in hemiparetic stroke patients. Stroke. 1995;26:101-105. Landin S, Hagenfeldt L, Saltin B, Wahren J. Muscle metabolism during exercise in hemiparetic patients. Clin Sci Mol Med. 1977;53:257-269. Ivey FM, Macko RF, Ryan AS, Hafer-Macko CE. Cardiovascular health and fitness after stroke. Topics in Stroke Rehabilitation. 2005;12:1-16. Macko RF, Smith GV, Dobrovolny CL, Sorkin JD, Goldberg AP, Silver KH. Treadmill training improves fitness reserve in chronic stroke patients. Arch Phys Med Rehabil. 2001;82:879-884. Silver KH, Macko RF, Forrester LW, Goldberg AP, Smith GV. Effects of aerobic treadmill training on gait velocity, cadence, and gait symmetry in chronic hemiparetic stroke: A preliminary report. Neurorehabil Neural Repair. 2000;14:65-71. Shephard RJ. Maximal oxygen intake and independence in old age. Br J Sports Med. 2009;43:342-346. Kalapotharakos VI, Michalopoulos M, Strimpakos N, Diamantopoulos KBS, Tokmakidis SP. Functional and neuromotor performance in older adults: Effect of 12 wks of aerobic exercise. American Journal of Physical Medicine & Rehabilitation. 2006;85:61-67. Vaynman S, Gomez-Pinilla F. License to run: Exercise impacts functional plasticity in the intact and injured central nervous system by using neurotrophins. Neurorehabil Neural Repair. 2005;19:283-295. Armstrong L, Balady GJ, Berry MJ, et al. ACSM's Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore Maryland: Lippincott Williams & Wilkins; 2006. de Bruin AF, de Witte LP, Stevens F, Diederiks JPM. Sickness impact profile: The state of the art of a generic functional status measure. Social Science and medicine. 1992 Oct;35:1003-1014.  13. 14. 15. 16. 17. 18. 19. 20.  21. 22. 23. 1.  Duncan PW, Wallace D, Lai SM, Johnson D, Embretson S, Laster LJ. The stroke impact scale version 2.0: Evaluation of reliability, validity, and sensitivity to change. Stroke. 1999 Oct;30:21312140. Hartigan I. A comparative review of the katz ADL and the barthel index in assessing the activities of daily living of older people. International Journal of Older People Nursing. 2007 September:204-212. Harwood RH, Ebrahim S. A comparison of the responsiveness of the nottingham extended activities of daily living scale, london handicap scale and SF-36. Disability & Rehabilitation. 2000 Nov;22:786-793. Loewen SC, Anderson BA. Reliability of the modified motor assessment scale and the barthel index. Physical Therapy. 1988 Jul;68:1077-1081. Parker CJ, Gladman JRF, Logan PA. Development and validation of the nottingham leisure questionnaire Clinical Rehabilitation. 2001 Dec;15:647-56. Rossier P, Wade DT, Murphy M. An initial investigation of the reliability of the rivermead extended ADL index in patients presenting with neurological impairment. Journal of Rehabilitation Medicine. 2001 Mar;33:61-70. Salter K, Jutai JW, Teasell R, Foley NC, Bitensky J, Bayley M. Issues for selection of outcome measures in stroke rehabilitation: ICF activity. Disability & Rehabilitation. 2005 Mar;27:315-40. Schepers VPM, Ketelaar M, van de Port IGL, Visser-Meily JMA, Lindeman E. Comparing contents of functional outcome measures in stroke rehabilitation using the international classification of functioning, disability and health. Disability & Rehabilitation. 2007 February;29:221-230. Schlote A, Krüger J, Topp H, Wallesch C. Inter-rater reliability of the barthel index, the activity index, and the nottingham extended activities of daily living: The use of ADL instruments in stroke rehabilitation by medical and non medical personnel Rehabilitation. 2004 Apr;43:75-82. Streppel KRM, van Harten WH, Warmerdam CGM. Short version of the sickness impact profile for evaluating rehabilitation programs. Journal of Rehabilitation Sciences. 1996;9:66-71. Van de Port IGL, Ketelaar M, Schepers VPM, Van den Bos GAM, Lindeman E. Monitoring the functional health status of stroke patients: The value of the stroke-adapted sickness impact profile30. Disability & Rehabilitation. 2004 Jun;26:635-640. Wilkinson PR, Wolfe CDA, Warburton FG, et al. Longer term quality of life and outcome in stroke patients: Is the barthel index alone an adequate measure of outcome? Quality in Health Care. 1997 Sept;6:125-130.  25. 26. 27. 28. 29. 30. 31. 32. 33. 34.  Katz-Laurer M, Carmeli E, Shochina M. The effect of early aerobic training on independence six months post stroke. Clin Rehabil. 2003;17:735-741. Katz-Leurer M, Shochina M, Carmeli E, Friedlander Y. The influence of early aerobic training on the functional capacity in patients with cerebrovascular accident at the subacute stage. Arch Phys Med Rehabil. 2003;84:1609-1614. Liston R, Mickelborough J, Harris B, Hann AW, Tallis RC. Conventional physiotherapy and treadmill re-training for higher-level gait disorders in cerebrovascular disease. Age & Ageing. 2000;29:311-318. Macko RF, Ivey FM, Forrester LW, et al. Treadmill exercise rehabilitation improves ambulatory function and cardiovascular fitness in patients with chronic stroke: A randomized, controlled trial. Stroke. 2005;36:2206-2211. Pohl M, Werner C, Holzgraefe M, et al. Repetitive locomotor training and physiotherapy improve walking and basic activities of daily living after stroke: A single-blind, randomized multicentre trial (DEutsche GAngtrainerStudie, DEGAS). Clin Rehabil. 2007;21:17-27. Smith PS. The effect of treadmill training on functional limitation and disability measures in persons in the chronic stage of recovery from stroke. Texas Woman's University; 2006. Chen C, Tang F, Chen H, Chung C, Wong M. Brain lesion size and location: Effects on motor recovery and functional outcome in stroke patients. Arch Phys Med Rehabil. 2000;81:447-452. Furlan M, Marchai G, Viader F, Derlon J-, Baron J-. Spontaneous neurological recovery after stroke and the fate of the ischemic penumbra. Ann Neurol. 1996;40(2:ate of Pubaton: Aug 1996. Rimmer JH, Rauworth AE, Wang EC, Nicola TL, Hill B. A preliminary study to examine the effects of aerobic and therapeutic (nonaerobic) exercise on cardiorespiratory fitness and coronary risk reduction in stroke survivors. Arch Phys Med Rehabil. 2009;90:407-412. Pollock MLPD, Facsm, Gaesser GAPD, F.A.C.S.M., et al. ACSM position stand: The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Medicine & Science in Sports & Exercise. 1998;30:975-991.  Questions?  

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