Cardiac Rehabilitation
for Stroke Patients
Dina Brooks,
Associate Professor
University of Toronto
Is it really survival
of the fittest?
Why study stroke?

Leading cause of neurological disability in
adults

40,000 – 50,000 strokes per year

300,000 stroke survivors in Canada

60% have functional impairments
Physical impairments
Weakness
 Reduced range of motion
 Sensory changes
 Altered muscle tone
 Impaired coordination
 Reduced exercise capacity/fitness level

Impact of reduced fitness

Activities of Daily Living

Altered walking
 2/3 of stroke survivors have impaired
walking function
 1/2 of stroke survivors are unable to
walk at all
Functional ambulation
The capacity to execute safe, efficient walking within time
and environmental constraints encountered in everyday
life
Sensorimotor
Control
Fitness
Functional Ambulation
Implications for function
Cardiorespiratory and walking deficits may
mutually reinforce one another
Impaired
walking
 mechanical efficiency
 metabolic costs
Limits activity
Sedentary lifestyle
Further weakness
Reduced
cardiorespiratory fitness
In addition…..

75% with history of heart disease

50 - 84% have high blood pressure

40% have severe coronary artery disease
Stroke risk factors
Hypertension
Atrial fibrillation
Smoking
High cholesterol
Diabetes
Obesity
Carotid stenosis
Physical Inactivity
Risk of second stroke or heart attack
Cardiovascular event
Stroke Rehab
Cardiac Rehab
-? 1-2 months
-Up to 12 months
-Functional recovery
-Supervised exercise program
-Little exercise training
-Education
-Little formal education
-Nutritional Support
Fitness in stroke:
What does the literature say?
Exercise program feasible in stroke
 Results in:

o
o
o
improved fitness level
reduced neurological impairment
enhanced lower extremity function
Changes in fitness levels from 8 to 23%
 Not uniform effect throughout the groups

Fitness in stroke:
What does the literature say?
Studies focus on exercise exclusively
 Generally less than three months

Why not use an established and common
model of care (cardiac rehabilitation) and
apply to the stroke population?
Cardiac rehabilitation model
Cardiac Rehab




Up to 12 months
Supervised exercise program
Education
Nutritional Support
Effects of Cardiac Rehabilitation for
Individuals Following Stroke
Heart & Stroke Foundation of Ontario
Stroke Rehabilitation Special
Competition #SRA 5977
Purpose

Establish feasibility of cardiac rehabilitation
for individuals with stroke

Determine the effects on:
 Exercise, walking capacity and ability
 Community re-integration
 Quality of life
 Risk factors for subsequent stroke
Design
Test 1
Test 2
Test 3
Test 4
Baseline
Cardiac Rehab program
3 months
6 months
Outcomes

Maximal exercise test
 Semi-recumbent cycle
ergometry
 VO2peak
Peak Work Rate
Peak Heart Rate

6-Minute Walk Test (6MWT)

Stroke Impact Scale (SIS)

Risk factor profile

Community reintegration
Intervention – Cardiac Rehab

Aerobic training 4-5 days / week
Resistance training 2 days / week

Education sessions

Training once a week at Centre

Exercise diary
Progress to date – Research

53 people have been recruited for the study

10 people were not entered, leaving 43
participants who enrolled into the study.

17 were able to walk without use of gait aids,
18 used a single point cane, 1 used a quad
cane and 7 used a walker or rollator.
Preliminary results
Participant Demographics - All
n=43 completed Baseline testing
Men / Women
30 / 13
Age
64 ± 13 (38-86)
Months post stroke
30 ± 28 (3-120)
Type: Isch / Hemorr / Unknown
28 / 10 / 5
R / L / Bilat hemisphere affected
16 / 25 / 2
Preliminary results
Changes during 3-month baseline period
(n=34)
0 months
3 months
p
VO2peak, mlkg1min-1
13.1 ± 4.8
14.9 ± 5.5
NS
Peak work rate,
watts
59.9 ± 30
61.3 ± 33
NS
Peak heart rate,
beats/min
110.8 ± 21
116 ± 23
NS
6-Minute Walk
Test distance,
267.9 ±
135
273.9 ±
122
NS
Preliminary results
Changes following program completion
(n=27)
0 months
3 months
VO2peak, mlkg1min-1
14.9 ± 5.5
16.6 ± 5.5
Peak work rate,
watts
61.3 ± 33
61.6 ± 31.9
Peak heart rate,
beats/min
116 ± 23
114 ± 23
6-Minute Walk Test
distance,
273.9 ± 132
299.4 ± 145.8
Preliminary results

No change in function during baseline 3
months

Attended 85% of scheduled classes

14% improvement in fitness level

9% reductions in BP

10% greater walking ability

6% lower relative stroke risk
Preliminary results

Subjects extremely satisfied with the
program and wish to continue

Adaptation required for the program

Partners satisfied and wish to participate
Discussion

Aerobic and functional capacity in this population is low.

In the absence of formal community-based exercise,
these measures remain unchanged.

Preliminary results suggest positive benefit to
cardiorespiratory fitness, blood pressure and lower stroke
risk

Ongoing data collection
How this research addresses the gap in
stroke care?
Present rehab programs for Stroke




? 1-2 months
Functional recovery
Little exercise training
Little formal education
That is not enough!
Impact on the community

It is time that we start using an
established and common model of care
(cardiac rehabilitation) in individuals with
stroke
Key messages
Fitness levels very low in stroke patients
 Rehabilitation should include a formal
exercise component
 Cardiac rehabilitation can be adapted for
patients with stroke
AND WE WILL CHANGE PRACTICE!

Acknowledgements

Toronto Rehabilitation Institute Neuro Rehab and Cardiac
Rehab Programs for their ongoing support and assistance
Research Team
William McIlroy and Dina Brooks
Scott Thomas
Mark Bayley
Paul Oh
Sandra Black
Jim Salhas
Ada Tang
Kathryn Sibley
Valerie Closson
Cynthia Danells
Hannah Cheung
Thank you!
Questions, comments…
Dina Brooks PhD
dina.brooks@utoronto.ca
Fitness in Community for Chronic Stroke
Purpose



To determine the proportion of fitness facilities in
the Greater Toronto Area (GTA) that provide
programs specifically developed for stroke
survivors.
To identify the components and resources utilized
by stroke specific fitness programs.
To determine perceived and actual barriers to
offering fitness programs for stroke survivors.
Methods
Cross-sectional descriptive study
 Questionnaire was distributed to 784
fitness facilities in the GTA asking

Results
Of 213 respondents, 146 facilities reported
that individuals with a chronic disability
participated
 62 facilities offered specific fitness
programs for individuals with a chronic
disability
 26 with stroke-specific fitness programs

Findings
Typical stroke fitness programs operated
as not-for-profit organizations, in large
facilities
 Specific acceptance criteria for stroke
survivors to participate
 Stroke-specific programs included aerobic,
flexibility training and strengthening.
