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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 Excluded after title screen 880 Excluded after de-duplication 46 Excluded after abstract screen 103 Excluded after full text screen 36 Handsearching occurred 3 Included after MS study removed 6 Included after handsearching 7 Included after full text screen 4 Included after abstract screen 40 Included after de-duplication 143 Included after title screen 189 Initial Search 1069 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 Participant mean age Initial # of participants I:C Final # of participants I:C Condition or Type of Stroke Time post- stroke Katz-Leurer 63 +/- 11 46 : 46 46 : 44 Hemorrhage, Infarction Not specified Liston 79.1 +/- 6.8 10 : 8  (Treadmill 1st: Conventional PT 1st) 8 : 8     (Treadmill 1st: Conventional PT 1st)  Leukoaraiosis, Infarct,  Low Density Area, Leukoaraiosis, Infarct Not specified Macko  63 +/- 10       32 : 29 25 : 20 Ischemic > 6 months Pohl  62.3 +/- 12 (range: 26 - 79)       77 : 78 72 : 72 (After 4 weeks) Ischemic, Hemorrhagic < 60 days Smith 57.8  (range: 42-72) 10 : 10 10 : 10 Ischemic > 3 months, < 2 years 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 -5 15 35 55 75 95 115 135 155 175 Katz-Leurer - FIM Smith - SIS Liston - Nottingham Macko -RMI Pohl - BI Pohl - RMI Study %  ch an ge Control % change (final- initial) Experimental % change (final- initial) Control % change at follow up (from initial) Experimental % change at follow up (from initial) Control % change at follow up (from final) 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. 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