Cardiac Rehabilitation

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Cardiac Rehabilitation for Stroke Patients Dina
Brooks, Associate Professor University 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

Sensorimotor Control
Fitness
Functional Ambulation
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Implications for function

• Cardiorespiratory and walking deficits may
  mutually reinforce one another

HEALTH RELATED QUALITY OF LIFE
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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 event

• Stroke Rehab
• ? 1-2 months
• Functional recovery
• Little exercise training
• Little formal education

• Cardiac Rehab
• Up to 12 months
• Supervised exercise program
• Education
• Nutritional Support

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Fitness in strokeWhat does the literature say?

• Exercise program feasible in stroke
• Results in
• improved fitness level
• reduced neurological impairment
• enhanced lower extremity function
• Changes in fitness levels from 8 to 23
• Not uniform effect throughout the groups

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Fitness in strokeWhat 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

• Before and after experimental design with
  baseline period
• Participants
• Community-dwelling stroke survivors
• gt 3 months post stroke
• Mild to moderate impairment

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Design
Cardiac Rehab program
Baseline
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Outcomes

• Maximal exercise test
• Semi-recumbent cycleergometry
• 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 / weekResistance
  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 results

• Participant Demographics - All
• n43 completed Baseline testing

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Preliminary results

• Changes during 3-month baseline period
• (n34)

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Preliminary results

• Changes following program completion
• (n27)

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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

Ada Tang Kathryn Sibley Valerie Closson Cynthia
Danells Hannah Cheung

• Scott Thomas
• Mark Bayley
• Paul Oh
• Sandra Black
• Jim Salhas

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Thank you!

• Questions, comments
• Dina Brooks PhD
• dina.brooks_at_utoronto.ca

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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.