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Aerobic Exercise Early After Stroke – no limits?

Comment by Nicolle Kraenkel, EACPR Exercise, Basic and Translational Research Section

Patient Characteristics that Influence Enrollment and Attendance in Aerobic Exercise Early After Stroke
EC Prout et al.
Arch Phys Med Rehabil. 2014 Dec 22. pii: S0003-9993(14)01316-1.


Structured aerobic exercise training is recommended for post-stroke rehabilitation. In contrast to other vascular diseases, such as coronary artery or peripheral artery disease, however, referral rates are lower in those patients.

The paper of Prout et al. investigates patient characteristics and discusses (perceived) limitations precluding the enrollment into structured exercise protocols or affecting the attendance rate in the stroke patients referred to the exercise training.
Out of the 338 stroke patients analysed, about one third were prescribed a structured exercise training protocol. Older and female patients were less likely to be referred to the exercise program. The strokes of non-referred patients originated more often from a cardioembolic source and they were more often suffering from cardiac disease or arthritis than patients actually referred to the exercise program. This is in contrast to current guidelines recommending structured exercise training for patients with cardiovascular disorders.

Whilst cognitive or perceptual deficits of stroke patients are often named by physiotherapists as a limiting parameter for performing structured exercise programs, in the current study cognitive impairment or dementia were not associated with enrollment into the exercise group.

However, one needs to keep in mind that the study was supported by an experienced interdisciplinary healthcare team and specialised exercise facilities, which might not be available to other providers. Therefore, this single-centre study might not be representative for many other settings and wider research is warranted.

The second part of the study investigated the influence of co-morbidities and patient characteristics on exercise attendance rates. Attendance rate in the exercise-referred patients was 77%, and was only associated with Functional Independence Measure rating at baseline, but not with individual cardiovascular or musculoskeletal comorbidities, or other parameters. It would be helpful in this respect to record the actual reasons causing the patient not to attend sessions, as Functional Independence Measure is a rather complex score.

Further investigation might show whether improved encouragement by the healthcare provider, further assistance in actions peripheral to the actual exercise session (such as preparation/clothing before and showering after each session), as well as better adaptation of the exercise regimen to the limitations of the patient can enhance attendance.

Technical means might furthermore help to devise less complex exercise regimens and support patients with physical limitations while not limiting exercise intensity, such as the semi-recumbent stepping machines used in this study.