Are Aerobic Programs Similar in Design to Cardiac Rehabilitation Beneficial for Survivors of Stroke? A Systematic Review and Meta‐Analysis

Nothing here tells you EXACTLY what aerobic exercise is and how much is needed.  So useless.  I would have these people fired. The only goal in stroke is 100% recovery and this doesn't meet that requirement.

Are Aerobic Programs Similar in Design to Cardiac Rehabilitation Beneficial for Survivors of Stroke? A Systematic Review and Meta‐Analysis

Elizabeth W. Regan

,

Reed Handlery

,

Michael W. Beets

, and

Stacy L. Fritz

Originally published14 Aug 2019https://doi.org/10.1161/JAHA.119.012761Journal of the American Heart Association. 2019;8

Abstract

Background

Survivors of stroke face movement disability and increased cardiovascular disease and stroke risk. Treatment includes rehabilitation focused on functional movement with less emphasis on aerobic capacity. After rehabilitation, survivors of stroke must self‐manage activity with limited appropriate community programs. Lack of structured activity contributes to sedentary behavior. The objective of this systematic review and meta‐analysis is to review aerobic programs for stroke survivors similar in activity and dosage to cardiac rehabilitation programs to determine their efficacy for improving aerobic and walking capacity.

Methods and Results

Preferred Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were used to review 5 databases. Group interventions for survivors of stroke with a primary aerobic component and dosage from 18 to 36 visits over 8 to 18 weeks (matching cardiac rehabilitation requirements in the United States) were included. The 6‐minute walk test, maximal oxygen consumption (VO2) peak, and walking speed were included as measures of aerobic capacity. Summary effect sizes and outcome measure mean differences were calculated for preintervention to postintervention, and summary effect sizes were calculated for preintervention to follow‐up. Activity type and initial 6‐minute walk test moderator analyses were performed. Nineteen studies with 23 eligible groups were selected. Survivors of stroke improved their composite aerobic capacity with an effect size of 0.38 (95% CI, 0.27–0.49). Studies including 6‐minute walk test demonstrated a pooled difference in means of 53.3 m (95% CI, 36.8–69.8 m). Follow‐up data were inconclusive.

Conclusions

Survivors of stroke benefit from aerobic programs with similar dosing to cardiac rehabilitation in the United States. The potential integration into existing programs could expand the community exercise options.

Clinical Perspective

What Is New?

• Reviewing efficacy of aerobic programs for survivors of stroke similar in activity and dosing to cardiac rehabilitation in the United States provides a prerequisite knowledge base for considering application of cardiac rehabilitation after stroke.
• Results of the systematic review and meta‐analysis indicate aerobic programs similar in activity and dosing to cardiac rehabilitation programs in the United States are effective at increasing aerobic capacity for survivors of stroke regardless of mode of exercise, functional mobility, or time since stroke.

What Are the Clinical Implications?

• Providing cardiac rehabilitation for survivors of stroke may positively impact health status and mobility without creating new programs; further research is warranted.

Introduction

Mobility impairments and accompanying sedentary behaviors are major health concerns for many of the 6.6 million survivors of stroke in the United States.¹ With a large number of survivors of stroke living with disability and facing a higher risk for stroke reoccurrence and other diseases, there is an increasing need for prevention and modification of risk factors.² Physical activity (PA) and exercise can positively impact a survivor's overall health by reducing risk factors and improving physical function and quality of life.^{3, 4} In addition, survivors of stroke engaging in PA can reduce risk for all‐cause mortality and reduce 3‐year risk for recurrent stroke, myocardial infarction, or vascular death.^{5, 6} The Centers for Disease Control and Prevention defines PA as “any bodily movement that is produced by the contraction of skeletal muscle and that substantially increases energy expenditure,” whereas exercise is a subset of PA “that involves planned, structured and repetitive bodily movement done to maintain or improve one or more components of physical fitness.”^{7, 8}
Many survivors of stroke receive rehabilitation care immediately after their stroke, which is focused primarily on recovery of function with limited or absent focus on aerobic fitness.^{9, 10} Patients are encouraged to continue with prescribed home exercise programs after discharge from rehabilitation, yet without support or guidance, most do not.¹¹ This drop‐off of services contributes to failure of transition from rehabilitation patient to community PA participant.¹² Survivors of stroke take less than half the daily steps of healthy counterparts and spend >78% of their time in sedentary behaviors, regardless of time since stroke.^{13, 14} Structured community exercise programs, such as cardiac rehabilitation (CR), can potentially reduce the deconditioning remaining after rehabilitation and improve habitual PA and exercise for survivors of stroke. Since 1994, the American Heart Association has recommended multidisciplinary CR programs as an integral part of recovery after cardiac events and for the tertiary prevention of cardiovascular disease. CR programs improve participants’ health through exercise and educational programs delivered by exercise physiologists and nurses, 2 to 3 times a week for 8 to 18 weeks with aerobic exercise for >30 minutes each visit.¹⁵ Currently, CR programs are offered only to individuals with specific cardiac diagnoses in the United States.¹⁶ Although survivors of stroke exhibit similar deficits in cardiovascular health, stroke is not among the covered diagnoses for CR services.^{16, 17} CR programs are generally widely available (in 2005, there were 2600 programs across the United States), with some variation across geographic areas.¹⁸
Several studies have tested the efficacy and feasibility of the multidisciplinary components of CR including aerobic exercise outside the United States, primarily in Canada.^{19, 20, 21, 22, 23, 24, 25, 26, 27} However, international differences in frequency and duration make conclusions for US programs difficult. Although the American Heart Association and American Stroke Association support CR for survivors of stroke, there has not been support for widespread adoption or testing.
The objective of this systematic review and meta‐analysis is to evaluate aerobic exercise interventions for survivors of stroke that are similar in dosing and activity to CR programs in the United States to determine their efficacy for improving aerobic and walking capacity. Secondary aims include the following: (1) evaluating whether gains are sustained in follow‐up and (2) evaluating if type of exercise impacts the results.