Exercise-based cardiac rehabilitation improves CV endurance, strength in stroke survivors

Stroke survivors who participated in exercise-based cardiac rehabilitation experienced improvements in CV endurance, strength and mobility, according to data published in the Journal of the American Heart Association.

“Our most important goal as health care professionals is to help stroke survivors reduce as many risk factors as possible to prevent future stroke or cardiovascular disease,” Elizabeth W. Regan, DPT, PhD, clinical assistant professor of exercise science in the physical therapy program at the University of South Carolina, said in a press release. “Based on these preliminary findings, we hope prescribing cardiac rehab will be considered for all patients following a stroke, as it is for patients after a heart attack.

“We need to place value on exercise as medicine,” Regan said in the release. “Exercise is health, and it is important for every individual, regardless of physical limitations or age. Hopefully, increasing physical activity can be one of the first steps to improving overall health following a stroke.”

For this analysis, survivors of subacute and chronic stroke were enrolled into a standard exercise-based, 12-week cardiac rehabilitation program with three sessions per week. Twenty-nine patients were enrolled, 24 completed the program (mean age, 62 years; 79% men; 25% Black) and 18 were available for 6-month follow-up.

“Through this study, we hoped to improve controllable risk factors for stroke survivors, and potentially prevent future stroke and cardiac events,” Regan said in the release. “Increasing physical activity is an important way to prevent stroke, and we wanted to see whether the rehab that patients receive after surviving a heart attack could have similar positive outcomes for patients who survive a stroke.”

Six participants who completed the program were lost to follow-up: one declined and five were lost because of facility closure due to the COVID-19 pandemic.

The most common comorbidities included high BP (83.3%), diabetes (41.7%), CVD (41.7%) and arthritis (29.2%).

Improvement in CV endurance, strength

No safety events related to exercise intensity were reported, and all participants met the prescribed rating of perceived exertion ranges.

Researchers observed improvements in the 6-minute walk test, the primary outcome measure for aerobic and walking capacity, which increased by 61.92 m (95% CI, 33.99-89.84) from the start of the program, and reported a large effect size (0.94), greater than the minimal detectable change of 34 m for survivors of stroke. This improvement was maintained at 6 months.

According to the study, participants maintained but did not improve walking speed, Activities-Specific Balance Confidence Scale score or Stroke Impact Scale (SIS) physical subscale score after the conclusion of the cardiac rehabilitation program.

“Qualitative themes related to endurance included improved stamina, improved stair climbing, and needing less rest breaks during activity,” the researchers wrote. “For some, improved endurance impacted their physical activity tolerance, and they were able to do more of what they enjoy.”

The five times sit-to-stand test, a measure of lower-extremity strength, also improved by a median of 2.85 seconds (interquartile range, 4.03) and was maintained at 6 months.

Moreover, the proportion of patients in the highest category for fall risk (Activities-Specific Balance Confidence Scale score < 67%) dropped from 33.3% before the program to 20.8% after it.

Researchers found no significant changes in general health outcome measures, including the remaining SIS subscales (SIS-Activities of Daily Living, SIS-Hand, SIS-Communication, SIS-Memory, SIS-Participation and SIS-Recovery).

Some participants reported changes, including weight loss and/or improved physical appearance, positive medication changes and improved awareness of the importance of health, according to the study.

Continuing exercise after cardiac rehabilitation

In other findings, all patients who completed the cardiac rehabilitation program had plans to continue exercise. Plans included continuing cardiac rehabilitation through the self-pay maintenance program, participating in group-based exercise classes, joining a gym for aerobic and strength activities, exercising at home and working with a personal trainer.

At 6 months, 83.3% of participants reported exercising at least once per week, 44.4% reported exercising one to three times per week and 38.9% reported exercise more than three times per week.

“Despite similar cardiovascular risk factors to traditional cardiac rehabilitation participants and potential health benefits from participation, stroke is not among the covered diagnoses for cardiac rehabilitation services in the United States,” the researchers wrote. “Findings support the use of cardiac rehabilitation exercise programs for survivors of stroke after rehabilitation to improve endurance, health status and quality of life. Further investigations can confirm findings and explore integrating survivors of stroke as a standard of care.”