• It is marked by an event (super-acute phase)
• future stroke should be prevented.
• There are multiple factors that impact rehabilitation
  • Medical Factor
    • Significance of the stroke
    • Comorbidities
    • Neurologic deficit (paralysis, aphasia, dysphagia, cognitive impairment)
    • Pain and spasticity
    • Fatigue (physical and mental)
    • Depression and anxiety
  • Psychosocial factor
    • Low social support —> complex rehab
    • Motivation and adherence
    • Cognitive and mental health issues
  • Rehabilitation landscape and environment
    • Access to care
    • Quality of care
    • Financial problems (e.g. therapy and assistive devices)
    • Accessibility of the home environment

Exercise training after stroke

• Movement become inefficient after stroke.
  • Residual impairments caused by the stroke
    • Hemiparesis
    • Spasticity
    • Cognitive dysfunction / Depression
    • Aphasia
    • Poor ‘mechanical’ efficiency and low fitness making PA more difficult.
• Reluctance to engage in exercise due to lack of awareness of exercise feasibility, lack of specialist
  • Awareness that exercise is feasible or desirable,
  • Access to resources to support exercise,
  • Structured exercise sessions whereby exercises could be demonstrated by a rehabilitation specialist or exercise leader
    
• The earlier the exercise is initiated, the better the repair of the brain lesion will be (imp to start early)

• 8 weeks, >20mins program, progression and sustained PA after the end of the program

Effect of exercise training in stroke

1. Immediately after acute stroke
2. Medically stable
   • Regaining PF
3. Long term secondary/tertiary prevention
   • 1. How to maintain a PA lifestyle and preventing a risk of another stroke.

Evidence for exercise training in stroke

• There will be an increase of 1 MET with Aerobic training
• 33m improvement in 6MWD (MCID for stroke is around 70m)
  • In respiratory, it is around 30m
• It is safe to perform aerobic training (or any other training programs) as many patients have went through such programs.
• It is important to specify the program (walking should be specified with intensity, stair climbing)

Implementation of exercise training in Stroke

• Screening assessment to identify medical conditions - Recommended
  • General information including
    • demographics, medical history, medications, cardiac history, seizure   history, diabetes control, lifestyle habits
• Assessment of contraindications to exercise testing and training
• Evaluate motor function, mobility, balance, swallowing, cognition and communication
• Incremental exercise test is recommended.
  • up to 75% of stroke victims have coexisting cardiac disease and 20-40% of asymptomatic stroke patients may have abnormal tests for silent cardiac ischemia, an incremental exercise test is recommended.
  • If it is not available, it is recommended to however start and initiate the training program. But, it will be difficult to monitor and prescribe intensity
  • 6MWD can be prescribed.
    
• Acute in pink and Medically stable in green
• Isometric exercises can be given in acute case, but more functional exercises to be prescribed later.

Recommendations for exercise programs

Special Consideration

• Monitor cardiovascular safety, HR (is there a irregular rhythm)
• Medications that affect the exercise program
• Modification of exercise devices (pedals on bikes)
• They would not usually feel the impairment or injury