Exercise-Based Stroke Rehabilitation: Clinical Considerations Following the COVID-19 Pandemic

 This is just guidelines, not helpful, we need EXACT PROTOCOLS LEADING TO 100% RECOVERY.

Exercise-Based Stroke Rehabilitation: Clinical Considerations Following the COVID-19 Pandemic

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Kevin Moncion, MSc, Lynden Rodrigues, MSc, Marilyn MacKay-Lyons, PhD, ...

First Published October 28, 2021 Review Article Find in PubMed 

https://doi.org/10.1177/15459683211054175

Article information

Abstract

Background. 

The COVID-19 pandemic attributable to the severe acute respiratory syndrome virus (SARS-CoV-2) has had a significant and continuing impact across all areas of healthcare including stroke. Individuals post-stroke are at high risk for infection, disease severity, and mortality after COVID-19 infection. Exercise stroke rehabilitation programs remain critical for individuals recovering from stroke to mitigate risk factors and morbidity associated with the potential long-term consequences of COVID-19. There is currently no exercise rehabilitation guidance for people post-stroke with a history of COVID-19 infection.  

Purpose. 

To (1) review the multi-system pathophysiology of COVID-19 related to stroke and exercise; (2) discuss the multi-system benefits of exercise for individuals post-stroke with suspected or confirmed COVID-19 infection; and (3) provide clinical considerations related to COVID-19 for exercise during stroke rehabilitation. This article is intended for healthcare professionals involved in the implementation of exercise rehabilitation for individuals post-stroke who have suspected or confirmed COVID-19 infection and non-infected individuals who want to receive safe exercise rehabilitation. Results. 

Our clinical considerations integrate pre-COVID-19 stroke (n = 2) and COVID-19 exercise guidelines for non-stroke populations (athletic [n = 6], pulmonary [n = 1], cardiac [n = 2]), COVID-19 pathophysiology literature, considerations of stroke rehabilitation practices, and exercise physiology principles. A clinical decision-making tool for COVID-19 screening and eligibility for stroke exercise rehabilitation is provided, along with key subjective and physiological measures to guide exercise prescription.  

Conclusion. 

We propose that this framework promotes safe exercise programming within stroke rehabilitation for COVID-19 and future infectious disease outbreaks.

Keywords

Stroke, COVID-19, exercise, rehabilitation, clinical practice guidelines, evidence-based practice

Introduction

The COVID-19 pandemic is attributable to the severe acute respiratory syndrome virus (SARS-CoV-2) which was first reported in December 2019.¹ This evolving pandemic has resulted in more than 83 million confirmed cases globally and more than 1.8 million deaths.² Older age and the presence of risk factors and co-existing comorbidities like stroke or cardiovascular disease increase an individual’s risk of infection, disease severity, and mortality after COVID-19.^3,4

While the acute and short-term complications of COVID-19 including respiratory,⁵ cardiovascular,^3,6,7 hematologic,⁸ and neurological⁴ sequelae have been reported extensively, emerging data highlight that major multi-system complications may persist 6-months after infection^2,9,10 (long haul or post-acute COVID-19 syndrome). Of concern for stroke recovery and rehabilitation, post-acute multimorbidity observed after COVID-19 potentially overlaps with similar multi-system effects of stroke.

Best practice guidelines strongly endorse interprofessional stroke rehabilitation programs for mitigating post-stroke health complications,¹¹ but in light of the COVID-19 pandemic, mitigating risk factors and morbidity associated with the short- and long-term consequences of COVID-19 is critical.^12,13

Exercise training is a recommended core component of stroke rehabilitation.^14,15 The majority of literature in individuals with stroke focuses on aerobic exercise training, but resistance and neuromuscular training are also critical aspects of a comprehensive program. Exercise training can facilitate functional recovery (e.g., mobility and cognitive function),^16,17 improved cardiorespiratory fitness,¹⁶ cardiovascular risk factors,¹⁸ muscular strength,¹⁹ and markers of neurorecovery.²⁰

Despite this substantial body of evidence, there are new challenges in the implementation of exercise training that are associated with the current COVID-19 pandemic,¹² and there is a lack of specific guidance for stroke rehabilitation service delivery. Indeed, the pandemic has led to significant changes in the delivery of all aspects of evidence-based stroke care,¹² where in-person and center-based activities are limited and physical distancing ensured to limit viral transmission.²¹ Specific to exercise following COVID-19 infection, guidelines and clinical decision making tools are available for return to play for athletes,^22-25 cardiac rehabilitation,^26,27 general rehabilitation,¹³ and acute stroke medical practices,²¹ but there is no guidance explicitly focused on exercise in the context of stroke rehabilitation.

Given the multi-system pathophysiology of COVID-19, stroke healthcare professionals are seeking guidance related to the safety and implementation of exercise rehabilitation for individuals post-stroke who may have suspected or confirmed COVID-19 infection and for ensuring a safe environment for exercise for individuals who have not been previously infected. Therefore, the objectives of this manuscript are to (1) review the multi-system pathophysiology of COVID-19 related to stroke and exercise; (2) discuss the potential benefits of exercise for individuals post-stroke with suspected or confirmed COVID-19 infection; and (3) provide clinical considerations related to COVID-19 for exercise during stroke rehabilitation, including safety considerations, pre-participation screening, and prescription. The considerations discussed herein were developed by an international panel of clinical and biomedical research experts in stroke rehabilitation, exercise physiology, and neuroscience and are not intended to be absolute or definitive but rather to help inform clinical decision-making for the implementation of exercise within stroke rehabilitation settings and does not consider public-health regulations that may vary between different jurisdictions. The target patient audience is individuals post-stroke with suspected or confirmed COVID-19 infection. However, this information is also relevant for individuals post-stroke who have not been infected but who want to exercise in a safe environment.

This manuscript is divided into two sections:

• 1. The Interaction of COVID-19, Stroke and Exercise includes an overview of known transmission properties of SARS-CoV-2 and a review of common pathophysiological changes in stroke and COVID-19 infection as they relate to immune, pulmonary, cardiac and vascular, neurological, and musculoskeletal system function. A discussion of the potential benefits of exercise training in stroke for mitigating pathophysiological complications of COVID-19 is also included.

• 2. Considerations for the Implementation of Exercise Stroke Rehabilitation During and After a Pandemic provides considerations to inform clinical decision making for the implementation of exercise, from pre-participation screening and prescription and progression beyond current clinical practice guidelines14,15 in the context of COVID-19.

  
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