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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.
One on One
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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