5
One on One The One-On-One Column provides scientifically supported, practical information for personal trainers who work with apparently healthy individuals or medically cleared special populations. COLUMN EDITOR: Paul Sorace, MS, RCEP, CSCS*D Exercise Programming for Stroke Survivors Peter Ronai, MS, RCEP, CSCS*D, NSCA-CPT*D, CSPS 1 and Paul Sorace, MS, RCEP, CSCS*D 2 1 Department of Physical Therapy and Human Movement Sciences, Sacred Heart University, Fairfield, Connecticut; and 2 Hackensack University Medical Center, Hackensack, New Jersey ABSTRACT THIS SPECIAL POPULATIONS COLUMN PROVIDES A BRIEF OVERVIEW OF STROKE AND THE POTENTIAL BENEFITS ENDUR- ANCE TRAINING AND RESISTANCE TRAINING CAN HAVE FOR IMPROVING PHYSICAL HEALTH AND FUNCTION IN MEDICALLY STABLE STROKE SURVIVORS. THIS COLUMN PROVIDES EXERCISE PROFESSIONALS WITH PROGRAM RECOMMENDATIONS FOR CLI- ENTS WHO ARE MEDICALLY CLEARED STROKE SURVIVORS. INTRODUCTION S troke survivors can experience a number of decrements in physi- cal fitness and functional capacity. Both aerobic training (AT) and resis- tance training (RT) have been shown to improve health-related components of physical fitness and ability to per- form activities of daily living (ADLs) (4,6,12). The accompanying Special Populations column provides a brief overview of the epidemiology, symp- toms, functional limitations of stroke (s), and potential benefits of AT and RT on preventing the recurrence of and managing stroke. Current AT and RT recommendations for stroke survivors are consistent with those for healthy populations (2,3). Both AT and RT exercises are recom- mended for stroke survivors who have been determined to be medically stable and cleared by their physician M.D./D. O. to exercise (1,2). This column will discuss exercise program recommen- dations for medically cleared stroke survivors. Exercise professionals (EPs) are encouraged to communicate with their clients’ physician M.D./D.O. and health care providers before working with stroke survivors. Physical activity goals and exercise prescriptions should be customized for each stroke survivor to maximize outcomes and facilitate long-term adherence. Current risk management recommen- dations include the implementation of low-to-moderate intensity aerobic activities, muscle strengthening exer- cises, and reduction of sedentary behavior(s) (2). The modes of AT and RT selected are typically determined by equipment availability, client prefer- ences, severity of physical/cognitive impairments, physical skill level(s), activity limitations, and participant re- strictions. As is the case with other special populations, obtaining medical clearance, other special medical pre- cautions, and recommended exercise contraindications and modifications from the client’s physician(s)/health care provider(s) is warranted (1,2). Stroke survivors are at increased risk of recurrent strokes and other cardio- vascular disease (CVD) and may be taking medications, which can affect physical activity tolerance, exercise re- sponses, exercise performance, and safety. EPs should be knowledgeable about these factors and recognize when exercise session modifications and/or termination are indicated and when immediate communication with a client’s physician/health care pro- vider is warranted. Stroke survivors are also at an increased risk of falling, and EPs should provide adequate supervision to promote their safety during AT and RT exercises (1,2,9). PRE-EXERCISE EVALUATION Although AT and RT are generally considered safe, many stroke survivors have comorbid CVD (2). Participants should undergo a preactivity medical/ health history screening to determine VOLUME 37 | NUMBER 1 | FEBRUARY 2015 Copyright Ó National Strength and Conditioning Association 56

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  • One on One

    The One-On-One Column provides scientificallysupported, practical information for personal trainerswho work with apparently healthy individuals or medicallycleared special populations.

    COLUMN EDITOR: Paul Sorace, MS, RCEP, CSCS*D

    Exercise Programming forStroke SurvivorsPeter Ronai, MS, RCEP, CSCS*D, NSCA-CPT*D, CSPS1 and Paul Sorace, MS, RCEP, CSCS*D21Department of Physical Therapy and Human Movement Sciences, Sacred Heart University, Fairfield, Connecticut; and2Hackensack University Medical Center, Hackensack, New Jersey

    A B S T R A C T

    THIS SPECIAL POPULATIONS

    COLUMN PROVIDES A BRIEF

    OVERVIEW OF STROKE AND THE

    POTENTIAL BENEFITS ENDUR-

    ANCE TRAINING AND RESISTANCE

    TRAINING CAN HAVE FOR

    IMPROVING PHYSICAL HEALTH

    AND FUNCTION IN MEDICALLY

    STABLE STROKE SURVIVORS. THIS

    COLUMN PROVIDES EXERCISE

    PROFESSIONALS WITH PROGRAM

    RECOMMENDATIONS FOR CLI-

    ENTS WHO ARE MEDICALLY

    CLEARED STROKE SURVIVORS.

    INTRODUCTION

    Stroke survivors can experiencea number of decrements in physi-cal fitness and functional capacity.

    Both aerobic training (AT) and resis-tance training (RT) have been shownto improve health-related componentsof physical fitness and ability to per-form activities of daily living (ADLs)(4,6,12). The accompanying SpecialPopulations column provides a briefoverview of the epidemiology, symp-toms, functional limitations of stroke(s), and potential benefits of AT and

    RT on preventing the recurrence ofand managing stroke.

    Current AT and RT recommendationsfor stroke survivors are consistent withthose for healthy populations (2,3).Both AT and RT exercises are recom-mended for stroke survivors who havebeen determined to be medically stableand cleared by their physicianM.D./D.O. to exercise (1,2). This column willdiscuss exercise program recommen-dations for medically cleared strokesurvivors. Exercise professionals (EPs)are encouraged to communicate withtheir clients physician M.D./D.O. andhealth care providers before workingwith stroke survivors. Physical activitygoals and exercise prescriptions shouldbe customized for each stroke survivorto maximize outcomes and facilitatelong-term adherence.

    Current risk management recommen-dations include the implementationof low-to-moderate intensity aerobicactivities, muscle strengthening exer-cises, and reduction of sedentarybehavior(s) (2). The modes of AT andRT selected are typically determinedby equipment availability, client prefer-ences, severity of physical/cognitiveimpairments, physical skill level(s),

    activity limitations, and participant re-strictions. As is the case with otherspecial populations, obtaining medicalclearance, other special medical pre-cautions, and recommended exercisecontraindications and modificationsfrom the clients physician(s)/healthcare provider(s) is warranted (1,2).Stroke survivors are at increased riskof recurrent strokes and other cardio-vascular disease (CVD) and may betaking medications, which can affectphysical activity tolerance, exercise re-sponses, exercise performance, andsafety. EPs should be knowledgeableabout these factors and recognizewhen exercise session modificationsand/or termination are indicated andwhen immediate communication witha clients physician/health care pro-vider is warranted. Stroke survivorsare also at an increased risk of falling,and EPs should provide adequatesupervision to promote their safetyduring AT and RT exercises (1,2,9).

    PRE-EXERCISE EVALUATION

    Although AT and RT are generallyconsidered safe, many stroke survivorshave comorbid CVD (2). Participantsshould undergo a preactivity medical/health history screening to determine

    VOLUME 37 | NUMBER 1 | FEBRUARY 2015 Copyright National Strength and Conditioning Association56

  • whether exercise is safe for them (1).In addition, a medical examinationcan help to identify neurologicalcomplications, other comorbidities,stroke-related limitations, and fallrisk, which either make exercise con-traindicated or necessitate that spe-cific exercise modification be made(1,2). Clients considered being athigher risk for cardiac events duringexercise by their physicians are typi-cally referred to a medically super-vised exercise and/or rehabilitationprogram by their physician M.D./D.O. (1,2). In addition, evaluation ofstroke severity can help EPs developrealistic exercise program goals withtheir clients, which improve theirhealth, physical fitness, and functionalcapacity.

    It is not within the scope of an EPspractice to evaluate the severity ofa stroke. Another medical professional(physician) should make this evalua-tion, and the EP can develop goalsbased on the evaluation. The 6-minute

    walk, self-selected walking velocity,timed stair climbing, Berg Balance,and the Timed Up and Go Testsare examples of valid functionalassessments that have been adminis-tered to stroke survivors (6,10,14).Readers are directed to the Rehabilita-tion Institute of Chicagos Rehabilita-tion Measures Database for a morecomprehensive list of functional out-come measures and test administrationand scoring procedures for stroke sur-vivors at: http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID5901.

    AEROBIC EXERCISE TRAINING

    AT activities should be part ofa comprehensive exercise program.Current exercise guidelines resemblethose of healthy individuals andshould emphasize increasing func-tional capacity, improving functionalindependence, and enhancing vascu-lar health (1,2). Although treadmilltraining has been shown to improve

    physical fitness, functional perfor-mance, and cardiovascular health inpersons with stroke (6), some clientsare at an increased risk of fallingand may become dizzy when chang-ing body positions rapidly or haveorthopedic limitations such as arthri-tis, osteoporosis, or postorthopedicsurgery. Treadmill training shouldnot be considered unless directsupervision is possible, and tread-mills are equipped with safety har-nesses. Therefore, client safety,disease severity, comorbidities, andfunctional limitations may warrantselection of other exercise modessuch as seated or recumbent cycleergometry or stepping and mayrequire other modifications to theAT program plan.

    Blood pressure (BP), heart rate (HR)(measured as pulse rate), and ratingof perceived exertion (RPE) monitor-ing before, during, and after exerciseis warranted for stroke survivorsduring AT. Some stroke survivors will

    Table 1AT program recommendations for stroke survivors

    Frequency 35 d/wk, either accumulated in $10-min sessions or all at once as best tolerated

    Intensity 4070% of HRR or 5580% of HRmax/or an RPE range of 1114 (of 20). Raising the treadmill elevation canincrease the workload for clients who are unable to increase their walking speed

    Type (mode) Large muscle group aerobic activities. A combination of standing (weight bearing) and seated (nonweightbearing) activities as appropriate, which can include: Treadmill walking, ground walking, stationary upper-and lower-body cycle ergometry, combined upper- and lower-body cycle, or step ergometry

    Handrails, partial unweighting (harness) systems, and gait belts can increase safety for clients who experiencelower extremity muscle fatigue or losses of balance. Clients who use assistive devices (canes, walkers, etc.)should use them when performing ground walking

    Foot straps, ace wraps, and glove-mitts can provide support for hemiparetic hands and feet during ergometry.

    Chairs placed along walking corridors can provide rest and/or recovery for clients experiencing fatigue

    Some clients using straps, wraps, and glove-mitts might not be able to release and move their limbs quicklyenough if they are experiencing a loss of balance and can be at an increased risk of falling. Close supervision iswarranted during ET. Close supervision during AT is warranted

    Monitoring Pulse rate, BP, and RPE conducted before, during, and after workouts can ensure exercise session safety

    Communication Written instructions, pictures, and frequent demonstrations can improve learning and retention of exercise tasksand safety procedures in clients with cognitive deficits

    AT5 endurance training; BP5 blood pressure; ET5 endurance training; HRmax5maximum heart rate; HRR5 heart rate reserve; RPE5 ratingof perceived exertion.

    Information obtained from Refs. 13,11,12.

    Strength and Conditioning Journal | www.nsca-scj.com 57

  • experience fatigue and unsteadinesswalking to and from exercise equip-ment and require guidance andsupervision getting to, on and off ofequipment. Foot straps and mitt-gloves can help survivors who expe-rience hemiparesis (weakness on 1

    side) and hemiplegia (paralysis on 1side) perform AT. EPs should knowtheir clients physician-determinedacceptable HR and BP ranges(2,9). Table 1 describes typical ATprogram recommendations for strokesurvivors.

    RESISTANCE TRAINING EXERCISE

    Resistance training exercise goalsand recommendations for medi-cally cleared stroke survivors shouldresemble those of healthy untrainedelderly individuals and be similar tothose for individuals after myocardial

    Table 2RT program recommendations for stroke survivors

    Frequency 23 d/wk with at least 48 h separating training sessions for the same muscle group. Greater frequency is requiredfor split routines (e.g. upper-body/lower-body workouts)

    Intensity Loads representing 5080% of MVV or 1RM can increase strength and endurance. Loading at lower intensitiesduring the initial learning stages of the RT routine is warranted in untrained, deconditioned, and elderlyclients

    RPE can enhance RT safety and effectiveness in clients who are able to communicate clearly

    Intensity/loading should be increased gradually as tolerance permits

    Diagrams and visual analogs can help clients with speech impairments communicate their RPE

    An RPE of 1114 of 20 is recommended for most clients

    Single limb sets reduce the amount of muscle mass activated and the hemodynamic responses (HR, BP, and RPP)

    Type (mode) 810 exercises involving major muscle groups in the chest, shoulders, back, hips, legs, arms, and abdomen

    Body weight exercises, machines, resistance bands/tubing, and free-weights are recommended. Each modalityhas been well tolerated and effective at improving muscular strength and endurance

    Single limb training might be necessary with hemiplegic clients

    Wraps, straps, and glove-mitts can enhance grip and control in hemiparetic limbs

    Repetitions 1015 repetitions per set

    Rest periods 6090 sthis time frame may vary depending on the exercise performed, clients training goals, health status,and tolerance

    Technique Maintain a regular breathing pattern (exhale during the lifting phase) and use controlled movements withina pain-free range

    Avoid straining (Valsalva Maneuver) and sustained hand gripping of equipment

    Sets 13 sets per exercise

    Safety Clients with neurological impairments might be at increased fall risk and seated/supported exercises can enhanceclient safety

    Avoid sudden body position changes in clients with balance impairments, neuropathies, and orthostaticintolerance (rapid BP and HR changes with sudden body position changes)

    Shoulder instability is very common in the hemiplegic shoulder.

    Terminate exercise if warning signs or symptoms, including dizziness, arrhythmias, unusual shortness of breath, oranginal discomfort occur

    HR, BP, and RPE conducted before, during, and after workouts and (as necessary) in between sets can ensuresafety during RT sessions

    1RM5 1 repetition maximum; BP5 blood pressure; HR5 heart rate; MVV5maximal voluntary contraction; RPE5 rating of perceived exertion;RPP 5 rate pressure product; RT 5 resistance training.

    Information obtained from Refs. 13,5,8,9,11.

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    VOLUME 37 | NUMBER 1 | FEBRUARY 201558

  • infarction (MI) (2,13). The goals ofan RT program should emphasizeimproving walking speed and effi-ciency, enhancing performance ofoccupational tasks and ADLs, andreducing cardiac demands during lift-ing and carrying tasks (1,2,13).

    Increased muscular strength canreduce the HR and BP responses andthe rate pressure product (RPP)(which is an indirect measure of myo-cardial oxygen demand) to a givenload during lifting tasks (5,7). Ratepressure product is expressed as RPP5 HR 3 SBP/100 (SBP 5 systolicblood pressure) (5). As absolutestrength increases, submaximal loadsnow represent a lower relative percent-age of a clients 1 repetition maximumstrength (7). In addition, single limbexercise sets reduce the total activemusculature and can reduce the hemo-dynamic response (HR, BP, and RPP)(11). This is particularly useful with cli-ents who have a higher resting BP and/or exercise BP.

    Clients RT program goals shouldbe individualized and address theirphysical limitations, functional capabil-ities, and comorbid conditions suchas hypertension, dyslipidemia, dia-betes, arthritis, and CVD risk factors(13,9,13). To enhance RT programsafety and efficacy, EPs should do thefollowing: Supervise their clients closely andmonitor BP, HR, and RPE before,during, and after RT.

    Know each clients physician-determined BP and HR limits.

    Place clients with neurological im-pairments in exercise body positionsand modalities, which reduce therisks of them losing their balanceand falling and potentially injuringthemselves seriously (1,9).

    Encourage stroke survivors toperform partial range of motion orunilateral RT exercises if they expe-rience hemiparesis or hemiplegia.

    Get medical clearance and ensure thattheir clients do not have congestiveheart failure, uncontrolled arrhyth-mias, severe valvular disease, uncon-trolled hypertension, and unstable

    angina (1). Readers are referred tothe American College of Sports Med-icine Guidelines for contraindicationsto starting an exercise program (1).

    Table 2 provides RT program recom-mendations for stroke survivors.

    SUMMARY

    Stoke survivors, when medicallycleared, can experience a number ofhealth and fitness-related benefits froma properly designed exercise program.As is the case with most specialpopulations, the EP must have a basicunderstanding of the mechanisms andcauses of a stroke, common medicaland other rehabilitative therapies, andthe expected exercise responses instroke survivors. Finally, to maximizesafety, EPs should know when torefer the person back to their physicianM.D./D.O.

    Conflicts of Interest and Source of Funding:The authors report no conflicts of interestand no source of funding.

    Peter Ronai is an associate clinicalprofessor of Exercise Science at SacredHeart University in Fairfield,Connecticut.

    Paul Sorace is a clinical exercise phys-iologist for the Cardiac Prevention andRehabilitation Center at HackensackUniversity Medical Center.

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