Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations

TLDR. This is for your doctor to read and understand. I bet there is almost zero chance that your doctor has read ANY of the 282 supporting references. 

Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations

Susan Marzolini^1,2,3*, Andrew D. Robertson^4,5, Paul Oh^1,2,3, Jack M. Goodman^1,2, Dale Corbett^3,6, Xiaowei Du^1,7 and Bradley J. MacIntosh^3,8

• ¹KITE, Toronto Rehab-University Health Network, Toronto, ON, Canada
• ²Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
• ³Canadian Partnership for Stroke Recovery, Toronto, ON, Canada
• ⁴Schlegel-University of Waterloo Research Institute for Aging, University of Waterloo, Waterloo, ON, Canada
• ⁵Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada
• ⁶Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
• ⁷School of Kinesiology and Health Studies, Queen's University, Kingston, ON, Canada
• ⁸Sunnybrook Health Sciences Center, Toronto, ON, Canada

Knowledge gaps exist in how we implement aerobic exercise programs during the early phases post-stroke. Therefore, the objective of this review was to provide evidence-based guidelines for pre-participation screening, mobilization, and aerobic exercise training in the hyper-acute and acute phases post-stroke. In reviewing the literature to determine safe timelines of when to initiate exercise and mobilization we considered the following factors: arterial blood pressure dysregulation, cardiac complications, blood-brain barrier disruption, hemorrhagic stroke transformation, and ischemic penumbra viability. These stroke-related impairments could intensify with inappropriate mobilization/aerobic exercise, hence we deemed the integrity of cerebral autoregulation to be an essential physiological consideration to protect the brain when progressing exercise intensity. Pre-participation screening criteria are proposed and countermeasures to protect the brain from potentially adverse circulatory effects before, during, and following mobilization/exercise sessions are introduced. For example, prolonged periods of standing and static postures before and after mobilization/aerobic exercise may elicit blood pooling and/or trigger coagulation cascades and/or cerebral hypoperfusion. Countermeasures such as avoiding prolonged standing or incorporating periodic lower limb movement to activate the venous muscle pump could counteract blood pooling after an exercise session, minimize activation of the coagulation cascade, and mitigate potential cerebral hypoperfusion. We discuss patient safety in light of the complex nature of stroke presentations (i.e., type, severity, and etiology), medical history, comorbidities such as diabetes, cardiac manifestations, medications, and complications such as anemia and dehydration. The guidelines are easily incorporated into the care model, are low-risk, and use minimal resources. These and other strategies represent opportunities for improving the safety of the activity regimen offered to those in the early phases post-stroke. The timeline for initiating and progressing exercise/mobilization parameters are contingent on recovery stages both from neurobiological and cardiovascular perspectives, which to this point have not been specifically considered in practice. This review includes tailored exercise and mobilization prescription strategies and precautions that are not resource intensive and prioritize safety in stroke recovery.