cardiac rehabilitation for stroke patients dina brooks, associate professor university of toronto
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Cardiac Rehabilitation for Stroke Patients
Dina Brooks, Associate ProfessorUniversity of Toronto
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Is it really survival of the fittest?
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Why study stroke?
Leading cause of neurological
disability in adults
40,000 – 50,000 strokes per year
300,000 stroke survivors in Canada
60% have functional impairments
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Physical impairments
Weakness Reduced range of motion Sensory changes Altered muscle tone Impaired coordination Reduced exercise capacity/fitness level
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Impact of reduced fitness
Activities of Daily Living Altered walking
2/3 of stroke survivors have impaired walking function
1/2 of stroke survivors are unable to walk at all
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Functional ambulation
The capacity to execute safe, efficient walking within time and environmental constraints encountered in everyday life
Functional Ambulation
Sensorimotor Control
Fitness
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Cardiorespiratory and walking deficits may mutually reinforce one another
Impaired walking
Reduced cardiorespiratory fitness
Limits activitySedentary lifestyleFurther weakness
mechanical efficiency metabolic costs
HEALTH RELATED
QUALITY OF LIFE
Implications for function
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In addition…..
75% with history of heart disease
50 - 84% have high blood pressure
40% have severe coronary artery
disease
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Stroke risk factors
Hypertension
Smoking
Diabetes
Carotid stenosis
Atrial fibrillation
High cholesterol
Obesity
Physical Inactivity
Risk of second stroke or heart attack
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Cardiovascular eventCardiovascular event
Cardiac Rehab-Up to 12 months
-Supervised exercise program
-Education
-Nutritional Support
Stroke Rehab-? 1-2 months
-Functional recovery
-Little exercise training
-Little formal education
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Fitness in stroke:What does the literature say?
Exercise program feasible in stroke Results in:
o improved fitness level o reduced neurological impairment o enhanced lower extremity function
Changes in fitness levels from 8 to 23%
Not uniform effect throughout the groups
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Fitness in stroke:What does the literature say?
Studies focus on exercise exclusively Generally less than three months
Why not use an established and common model of care (cardiac rehabilitation) and apply to the stroke population?
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Cardiac rehabilitation model
Cardiac Rehab Up to 12 months Supervised exercise program Education Nutritional Support
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Effects of Cardiac Rehabilitation for Individuals Following Stroke
Heart & Stroke Foundation of Ontario
Stroke Rehabilitation Special Competition #SRA 5977
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Purpose
Establish feasibility of cardiac rehabilitation for individuals with stroke
Determine the effects on: Exercise, walking capacity and ability
Community re-integration
Quality of life
Risk factors for subsequent stroke
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Design
Cardiac Rehab programBaseline3 months 6 months
Test 1 Test 2 Test 3 Test 4
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Outcomes
Maximal exercise test Semi-recumbent cycle
ergometry
VO2peakPeak Work RatePeak Heart Rate
6-Minute Walk Test (6MWT) Stroke Impact Scale (SIS)
Risk factor profile Community reintegration
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Intervention – Cardiac Rehab
Aerobic training 4-5 days / week
Resistance training 2 days / week
Education sessions
Training once a week at Centre
Exercise diary
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Progress to date – Research
53 people have been recruited for the study
10 people were not entered, leaving 43 participants who enrolled into the study.
17 were able to walk without use of gait aids, 18 used a single point cane, 1 used a quad cane and 7 used a walker or rollator.
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Preliminary resultsParticipant Demographics - AllParticipant Demographics - All
n=43 completed Baseline testing
Men / Women 30 / 13
Age 64 ± 13 (38-86)
Months post stroke 30 ± 28 (3-120)
Type: Isch / Hemorr / Unknown 28 / 10 / 5
R / L / Bilat hemisphere affected 16 / 25 / 2
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Preliminary results
Changes during 3-month baseline periodChanges during 3-month baseline period(n=34)
0 months 3 months p
VO2peak, mlkg-1min-1
13.1 ± 4.8 14.9 ± 5.5 NS
Peak work rate, watts
59.9 ± 30 61.3 ± 33 NS
Peak heart rate, beats/min
110.8 ± 21 116 ± 23 NS
6-Minute Walk Test distance,
267.9 ± 135
273.9 ± 122
NS
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Preliminary results
Changes following program completionChanges following program completion(n=27)
0 months 3 months
VO2peak, mlkg-
1min-1
14.9 ± 5.5 16.6 ± 5.5
Peak work rate, watts
61.3 ± 33 61.6 ± 31.9
Peak heart rate, beats/min
116 ± 23 114 ± 23
6-Minute Walk Test distance,
273.9 ± 132 299.4 ± 145.8
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Preliminary results
No change in function during baseline 3 months
Attended 85% of scheduled classes
14% improvement in fitness level
9% reductions in BP
10% greater walking ability
6% lower relative stroke risk
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Preliminary results
Subjects extremely satisfied with the program and wish to continue
Adaptation required for the program
Partners satisfied and wish to participate
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Discussion
Aerobic and functional capacity in this population is low.
In the absence of formal community-based exercise, these measures remain unchanged.
Preliminary results suggest positive benefit to cardiorespiratory fitness, blood pressure and lower stroke risk
Ongoing data collection
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How this research addresses the gap in stroke care?
Present rehab programs for Stroke ? 1-2 months Functional recovery Little exercise training Little formal education
That is not enough!
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Impact on the community
It is time that we start using an established and common model of care (cardiac rehabilitation) in individuals with stroke
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Key messages
Fitness levels very low in stroke patients
Rehabilitation should include a formal exercise component
Cardiac rehabilitation can be adapted for patients with stroke
AND WE WILL CHANGE PRACTICE!
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Acknowledgements
Toronto Rehabilitation Institute Neuro Rehab and Cardiac Rehab Programs for their ongoing support and assistance
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Research Team
William McIlroy and Dina Brooks
Scott ThomasMark BayleyPaul OhSandra BlackJim Salhas
Ada TangKathryn SibleyValerie Closson Cynthia DanellsHannah Cheung
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Fitness in Community for Chronic Stroke
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Purpose
To determine the proportion of fitness facilities in the Greater Toronto Area (GTA) that provide programs specifically developed for stroke survivors.
To identify the components and resources utilized by stroke specific fitness programs.
To determine perceived and actual barriers to offering fitness programs for stroke survivors.
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Methods
Cross-sectional descriptive study Questionnaire was distributed to 784
fitness facilities in the GTA asking
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Results
Of 213 respondents, 146 facilities reported that individuals with a chronic disability participated
62 facilities offered specific fitness programs for individuals with a chronic disability
26 with stroke-specific fitness programs
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Findings
Typical stroke fitness programs operated as not-for-profit organizations, in large facilities
Specific acceptance criteria for stroke survivors to participate
Stroke-specific programs included aerobic, flexibility training and strengthening.