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Lower Extremity Strength and Cardiovascular Training in the Post-Stroke Population:
Interpreting and Applying the Evidence
Melanie Lomaglio, PT, MSc., NCS
[email protected]
Lindsay Perry, PT, DPT, NCS
[email protected]
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Course Objectives:
Differentiate between the terms: muscle strength, muscle force, joint torque, and muscle
power
Differentiate between mechanical and neurological components of normal and abnormal
muscle force generation
Review the length tension relationship and force velocity curves and relate them to joint
torque and the post stroke population
Understand the influence of strength training on spasticity
Explain the relationship between muscle strength and function for both healthy adults and
post stroke adults
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Course Objectives
Understand maximal, submaximal exercise testing, and the alternative objective measures of
the cardiovascular system (i.e. VO2 peak, 6 minute walk test)
Explore various treatment options to improve strength and cardiovascular function
Explore the relationships between cardiovascular fitness, quality of life, and functional
mobility
Prescribe an appropriate muscle strengthening and aerobic exercise program for an
individual post stroke
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Course Outline
Introduction
Provide a rational for our topic selection
Part I: Strength Training
Mechanisms of force production and post stroke weakness
AHA/ASH, ACSM and CDC recommendations
Practical treatment ideas for various modes of strength training
Clinical cases/Discussion
Part II: Cardiovascular Training
Differentiate between Physical Activity and Exercise
Assessment of the Cardiorespiratory system
Identify challenges of implementing an aerobic program
Review the evidence supporting aerobic training guidelines for patients post stroke
Discuss Clinical Case
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Rational for session
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There is strong evidence to recommend low to moderate intensity aerobic activity, muscle
strengthening, and a reduction of sedentary behavior for post stroke care (Billinger et al.,
2014)
Aerobic and resistance exercise is currently underutilized in post-stroke care
Let’s make a change

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Muscle Strength
DOES STRENGTH = MUSCLE FORCE?
Muscle force is extremely difficult to measure:
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Muscle Strength
Lieber:
STRENGTH = JOINT TORQUE
= Muscle Force (N) x Moment Arm (m)
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Muscle Force
Mechanical Properties
Cross sectional area
Muscle Fiber type
Length tension relationship
Force-Velocity relationship
Neurological Properties
Central Motor Drive
Rate coding

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Length-tension Relationship: predicts the amount of force generated
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Force-velocity relationship
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Weakness Following Stroke:
HISTORICALLY:
Weakness overlooked by clinician
Strength training not believed to be effective in people with brain damage
High effort and resistance training thought to worsen spasticity (Bobath: 1990)

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Weakness Following Stroke
TODAY:
Weakness is recognized as a primary impairment
Strength and functional performance are strongly correlated (Kim and Eng 2003, Lomaglio
and Eng 2004, Ng and Hui-Chan 2012, Dorsch et al. 2012, Patten et al. 2013)
Strength training is effective (Morris et al. 2004, Pak and Patten 2008, Billinger 2014)
Resistance training does NOT worsen spasticity (Morris et al., 2004, Patten et al. 2004, Ada et
al. 2006, Pak and Patten 2008, Flansbjer et al. 2008)

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Weakness Following Stroke
 Impaired central motor drive
 Reduced firing rates and impaired rate coding
Compensate with additional motor unit recruitment
 Abnormal Co-contraction of antagonist
Active restraint to agonist force production
 Narrowed firing thresholds
 Slower speed of contraction (54 % slower)
 Type II fiber atrophy
 Evidence of bilateral weakness (“less affected” side)


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Weakness Following Stroke
Shorter and stiffer muscle fibers
Reduced sarcomeres in series, infiltration of connective tissue
Passive restraint to the agonist
Relative preservation of eccentric torque occurs bilaterally (Eng et al., 2009)
Concentric torque-velocity curve altered
With increasing speed, paretic limb torque decreases at a greater rate than the
nonparetic side
40-60% for paretic UE vs 10-15% for nonparetic as speed increased from 30-120 deg/s
(Patten 2004)
Isometric torque-angle curve altered
Exaggerated weakness at short muscle lengths with relative preservation at long lengths

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Torque-angle curve in the paretic knee extensors
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Descriptive Research Suggests
Passive stretching to prevent stiffness
Prevent atrophy via strength training
Strengthen paretic muscles over short lengths
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Harness eccentric strength preservation
More efficient and higher force production
Incorporate exercises that increase speed of contraction for power
Incorporate exercises that work on slow contractions to increase force
Address the non-paretic limb to prevent weakness and to promote cross education
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American College of Sports Medicine (ACSM) Scientific Recommendations for
Sedentary Older Adult (Garber et al. 2011)
1 set of 10-15 reps of each major ms group
40-50% of 1RM (very light to light intensity)
2-3 d/week
Rest ≥48hrs
Gradual progression to:
2-4 sets
Rest 2-3mins between
60-70% of 1RM for novice to intermediate
≥ 80% of 1RM for experienced
< 50% 1 RM and 15-20 reps for endurance
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American Heart and Stroke Association (AHA/ASA) Scientific Recommendations for
Stroke Survivors (Billinger et al., 2014)
At least 1 set of 10-15 reps of 8-10 exercises (torso, upper and lower extremities)
50-80% of 1 RM
2-3 days/week
Progress to 2-3 sets

Note: There are no specific protocols to guide physical activity prescription in the first 48
hours post stroke but muscular strength and endurance is recommended for in-patient
rehabilitation and out-patient settings once the patient is medically stable
Exercise programs should be developed by trained exercise professionals and should be
offered early after stroke
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Centers for Disease Control & Prevention (CDC): older adult recommendations:
supervised
not
≥ 2 days/week
≥ 1 set of 8-12 reps (more benefit with 2-3 sets)
 Rest 2-3 min between sets
Begin with no weight and re-assess bi-weekly
If you can lift the wt >12 times with good form it’s time to increase weight
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If you can’t do ≥8 reps then you should reduce the weight
Work all major muscle groups (program online)
Legs, hips, back, chest, abdomen, shoulders, and arms
W/u 5-10mins
Cool down with stretching (30-60s for older adult)
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Pre-Screening Important
Complete medical history
Assess strength, balance, cognition, behavior, communication
Medical Clearance
Physical Readiness Questionnaire (PAR-Q)
Obtain medical clearance for patients with cardiac co-morbidities
Assess vitals
Assess BP before
Supine, sitting, standing
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Calculating 1 RM indirectly with submax estimation online calculator
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Calculating by hand with coefficients
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Estimating 1RM based on 10RM
(may take some trial and error)
10 reps to fatigue (can do NO more) ≈ 75% of the 1 RM (Brzycki 1998)
If patient can perform 10 reps (and NO more) of knee extension with 7 lbs we can determine
his 1 RM

1 RM = 7 lbs/.75
1RM = wt lifted/%1RM
1 RM = 9 lbs
Now you can select whatever % is appropriate for training
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Successful and Safe PRT protocols from the RCT literature
1 Ouellette et al., 2004: Chronic stroke
3x/week for 12 weeks, Keiser pneumatic leg press, knee and ankle flex and ext
Warm up: 1 set of 4 reps at 25% 1RM
3 sets of 8 to 10 reps at 70% 1RM
Intensity increased bi-weekly by determining the 1RM
2 Flansbjer et al., 2008: Chronic stroke
2x/week for 10 weeks, pneumatic device, knee flex and ext
Warm up: 5mins on bike, 1 set of 5 reps 0 weight
1set of 5 reps at 25%
2 sets of 6-8 reps at 80% 1 RM
2 min rest between
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Intensity increased bi-weekly
Stretching to cool down
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Eccentric only training:
No superior benefit over other training modes have been demonstrated yet but carry over
to function looks promising (Fernandez-Gonzalo et al., 2014, Clark and Patten 2012)
Potent training stimulus
More efficient
Relative preservation (train at higher loads)
Research is limited
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Power Training:
Concentric phase as quick as possible/Eccentric phase controlled over 2-4 sec
Fall prevention
Alerted torque-velocity curve
Promising in the paretic UE (Patten et al. 2013) and older adult for improving functional
performance (Sayers 2007)
Start at a lower intensity and progress (Puthoff CSM 2015)
Must develop a base first, then increase speed
 8-12 reps, 1-3 sets
20-40% of 1RM to start, increase to 60-70% 1 RM
Weight bearing / function based exercise, shuttle, and pneumantic Keiser devices
Weighted vests (start at 2% of body weight and add 1-2% as able) and theraband
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Functional Training:
Repeated standing up and sitting down
Lower seat height
Bias weaker extremity
+/- use of UE’s for different phases of movement
Step ups/downs/ lateral
Raise step height
Heel raises
Lunges
Squats/mini squats
Walking against resistance
Part task practice
Ex: trailing leg position with theraband
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Functional Training
Cook et al. 2014
Limited research on functional progressive repetitive training
Cook et al. (2014) compared 102 acute post stroke patients on:
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CPT vs CPT+FST vs CPT+CPT
Both extra therapy groups (1+hr) showed greater improvement in gait speed compared to
the control
No group differences for strength
SAMPLE FST:
5 reps of STS from 40 ◦
Once 5 sets of 10 achieved, ht was lowered
Progressed to 5 sets of 10 from 120◦
Stair climbing similar protocol
Other activities included transfer training, gait and BWSTT
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Cross-Education Training
Clark and Patten (2012) reported a significant transfer effect to nonparetic untrained LE after
both concentric (12%) and eccentric (14%) isokinetic power training of the paretic LE
Gragert and Zehr (2013) reported a 31% increase in torque in the paretic untrained
dorsiflexors and a 35% in the nonparetic trained dorsiflexors after isometric training with no
significant difference in the amount of increase
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Implications for the severely weak
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RISKS of Progressive Resistance Training (PRT)
Morris et al (2004) systematic review of PRT reported no major adverse events (N = 201)
2 subjects reported musculoskeletal pain in knee and back
No missed sessions and no analgesia needed
Burr et al. (2012)
“Adverse events during resistance training are nearly non-existent”
Falls
Valsalva / transient HTN
Delayed onset muscle soreness (DOMS)
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Other considerations:
Strength training in the very weak (<3/5)
Consider open-chain
Consider eccentric training
Electrical-stim with or without voluntary contraction
Biofeedback
Mental imagery
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Do improvements in strength cause improvements in function?
There is conflicting evidence that changes in strength result in improvements in ADL
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performance, distance walked or gait speed (refer to ebrsr.com for a review)
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Systematic reviews also conflict:
Pak and Patten 2008: +ve strength, + function, + participation
Ada et al 2006*: +ve strength, + function
Morris et al 2004: +ve strength, –ve function

*Ada et al., 2006 included studies with mental imagery, biofeedback and muscle re-education
repetitive training
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Possible explanations:
Many studies examine isometric torque only
Gait is complex
Non-linear relationship between gait and function has been demonstrated in both healthy
(Buchner et al. 1996) and post-stroke subjects (Carvalho et al. 2013)
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Other considerations:
Capacity and Capability via
Multi-modal Exercise
1 Prevent atrophy and increase strength
Increase physical fitness
Reduce osteoporosis
Reduce fatigue
Decrease cardiovascular risk
Increase mobility
Reduce depression and social isolation
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2 Strength, endurance, and possibly power training for fall prevention
Aerobic
Circuit Training
Flexibility
Neuromuscular (balance coordination)
Functional training
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Key References and Resources
Position Statements:
Billinger SA, Arena R, Bernhardt J et al. Physical Activity and Exercise Recommendations for
Stroke Survivors. A Statement for Healthcare Professionals From the American Heart
Association/American Stroke Association. Stroke. 2014;45:2532-2553.
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Garber CE, Blissmer B, Deschenes MR, et al. Quantity and Quality of Exercise for Developing
and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently
Healthy Adults: Guidance for Prescribing Exercise. Med Sci Sports Exerc. 2011;43:1334-1359.
http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html. accessed March 16,
2015.
Critical and Systematic Reviews:
Ada L, Dorsch S, Canning CG. Strengthening interventions increase strength and improve
activity after stroke: a systematic review. 2006;52:241-248.
Gray V, Rice C, Garland SJ. Factors that Influence Muscle Weakness Following Stroke and
Their Clinical Implications: A Critical Review. Physiother Can. 2012;64;415-426.
Morris SL, Dodd KJ, Morris ME. Outcomes of Progressive Resistance Strength Training
Following Stroke: A systematic Review. Clin Rehabil. 2004;18:27-39.
Pak, S and Patten, C. Strengthening to Promote functional recovery poststroke: An Evidence
Based Review. Top Stroke Rehabil. 2008;15: 177-199.
Evidenced-Based Review of Stroke Rehabilitation: www. ebrsr.com
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Clinical Cases / Lab / Discussion
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Cardiovascular (CV) Training
They What, Why and How
AKA…
Exercise Training, Cardiorespiratory fitness, Aerobic Training, Physical Activity, Functional
Training, Exercise Prescription
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Risks for primary (and secondary) stroke
Non Modifiable Factors
Age, gender, genes

Modifiable
Behavior, sedentary lifestyle
Health choices: smoking, food intake, exercise
Higher stroke severity is strongly correlated with sedentary behavior
Survivors of mild severity Stroke spend 81% of day sedentary 1 year post stroke (Tieges,
et al 2014)
Despite relatively good functional recovery
Interrupted versus Total sedentary time
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Effect of Stroke on the systems
Increased risk for fatigue
Chronic fatigue
Exertional Fatigue

Negative cycles created and reinforced:
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Motor impairments limit function, increase energy expenditure
functional
limitations limit activity
sedentary lifestyle increases risk for fatigue
fatigue limits desire to be physically active
more fatigue generated and more
impaired CV and strength systems

Mental Health
Increased risk of Depression
Will impact compliance and motivation with an exercise program
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Effects of Stroke on Muscle Composition
Wasting
Intramuscular fat
Change from slow to fast twitch
Inflammatory cytokines
Reduced capillaries per muscle fiber
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Effect of stroke on Cardiovascular System
Increased levels of pro-inflammatory markers
Abnormal glucose and insulin metabolism
Impaired autonomic control
Respiratory dysfunction
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Adhering to Exercise: Limitations
Self- efficacy
Family involvement may play a key role (Galvin 2011)

Behavior modification/change required

Transtheoretical model (Prochaska, 1997)
Do you consider not doing your exercise to be a problem?
Are you bothered by not doing the exercise?
Are you interested in doing the exercise?
Are you prepared to do something to start doing the exercise?
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Physical Fitness:
A set of measurable health and skill related attributes including; ability to carry out daily
activities without undue fatigue.
Physical Activity Defined:
“Any bodily movement produced by skeletal muscles that results in energy expenditure”
*therapeutic activities*
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Exercise Defined:
“A subset of physical activity that is structured, planned, and repetitive and has a final or
intermediate objective for the improvement or maintenance of physical fitness”. Exercise is
intentional.
*therapeutic exercise*

Physical Therapists are Movement Specialists: But do/should we define ourselves as Exercise
Specialists?
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Goals of Exercise Training
Prevent secondary complications after acute stroke:
Learned disuse
Metabolic dysfunctions of the multiple organ systems
Regain pre-stroke levels of activity as soon as possible
Interventions for motor recovery should include strength and CV training (CPG DOD,
2010)
Increase in submax exercise tolerance improves ADL function
Lower energy cost during functional mobility
Self-management: confidence, empowerment
Physical activity counseling intervention plan (Joubert et al, 2009)
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Task Specific Training of the CV system: Challenges
Risk of a cardiovascular event, or second stroke
Limited time in therapy: Priorities
Mode of aerobic exercise
Physical limitations
Social Support
Access to equipment
Limited knowledge of therapist regarding:
Testing capacity of cardiorespiratory fitness
Implementing and progressing programs
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Considerations of Risks of exercise training post Stroke
Secondary Stroke?

Myocardial Infarction?

Muscular Injury?

Limited evidence regarding sentinel events during exercise tolerance testing (Zehr, 2011)

75 % survivors have concomitant CV disease (Billinger 2014)
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Measuring CV capacity
Exercise tolerance testing (ETT): (Zehr, et al) (Billinger et al 2014)
Maximal Tolerance Testing
Bruce Protocol: Treadmill
Submaximal Tolerance Testing
https://youtu.be/wZe9TJQVc1Q
YMCA Protocol

ETT Guides prescription of intensity as a function of Max HR (HRmax) or % of Heart Rate
Reserve

Low
Moderate
Vigorous
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How do I measure my patient’s CV system/endurance?
Resting Heart Rate (RHR): Karvonen Formula*
Consider limiting factors of accurate assessment: Beta Blockers
Blood pressure
SpO2
2, 6 or 12 minute walk test
Can correlate to Peak VO2 with low to moderate reliability (Courbon, 2006, Tang, 2006)
MCID 6MWT: 50 meters in mixed population (Perera et al.)
VO 2 Max/peak via metabolic cart
Normal values needed for independent living: 15-18 mlkg.min-1
Measuring Effort
BORG: 12 to 14 on the Borg Scale suggest a moderate level of intensity of physical
activity (Ammann et al, 2014)
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Heart Rate Calculations
Heart Rate Reserve:
Heart Rate Max (HRmax) – Resting Heart Rate (HRrest)
Estimated Max Heart Rate:
220-age
Predicted Max Heart Rate
206.9-(.67 x age)
Estimated Max HR on Beta Blocker
164-(.7 x age)
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Targer Heart Rate (THR)
HRrest + (%age of HRR)
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Parameters of a CV exercise program
Volume
500-1,000 METS per week
Intensities
Low
Moderate
Vigorous
Frequency
3-5 days/week
Duration per day
20 minutes, 30 minutes, 60 minutes (pending intensity)
Multiple 10 minute bouts
Steady State versus Interval Training
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Calculating VO2 Max
VO2 max (mL·kg(-1)·min(-1)) = 70.161 + (0.023 × 6MWT [m]) - (0.276 × weight [kg]) - (6.79
× sex, where m = 0, f = 1) - (0.193 × resting HR [beats per minute]) - (0.191 × age [y]).

6 minute walk as a predictor of VO2 Max
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Exercise Intensity
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Exercise Intensity
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ACSM Cardiovascular Guidelines: Older Adult
30 minutes minimum of Moderate intensity, 5 days a week
20 minutes of vigorous intensity, 3 days a week
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Prescription considerations
Aerobic instensity: VO2, Heart Rate, BP

Neuromuscular intensity: Speed, Watts, reps/time: Rate
Intensity within this system promotes neuroplasticity
Aerobic reflects NM intensity
Hornby, 2011

Intensity leads to greater production of Brain Derived Neurotrophic Factors (BDNF) (Mang
2013)
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Clinical Case/ Lab/ Discussion
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Quick References Guide
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Position Statements:
Billinger SA, Arena R, Bernhardt J et al. Physical Activity and Exercise Recommendations for
Stroke Survivors. A Statement for Healthcare Professionals From the American Heart
Association/American Stroke Association. Stroke. 2014;45:2532-2553.
Garber CE, Blissmer B, Deschenes MR, et al. Quantity and Quality of Exercise for Developing
and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently
Healthy Adults: Guidance for Prescribing Exercise. Med Sci Sports Exerc. 2011;43:1334-1359.
http://www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html
Critical Analysis/ Systematic Reviews
AEROBICS Best Practice Recommendations: http://strokebestpractices.ca/wpcontent/uploads/2013/07/AEROBICS-FINAL-July-2013.pdf
Amman et al. Application of exercise principles in subacute and Chronic Stroke survivors: a
systematic review. BMC Neurology 2014: 14:167
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FPTA Spring Conference 2015: Lower Extremity Strength and Cardiovascular Training in the Post-Stroke
Population: Interpreting and Applying the Evidence
CASE 1: A 65 year old male is referred to outpatient physical therapy 6 months post R MCA ischemic
stroke. The patient reports that he has fallen twice in the last 3 months. The patient has a history of
HTN but no other significant co-morbidities. The patient played golf prior to his stroke but he was not
an avid exerciser. The physician has cleared him for vigorous exercise.
Patient Goals: Reduce fall risk, improve walking speed and strength
BP: sitting 135/87, Standing 133/85, HTN controlled with Atenolol
Resting HR: 75bpm
Gait: mod I with single point cane for household distances. Mod I with single point cane on level terrain,
supervision / min A for curbs and uneven terrain. During swing phase, intermittent foot drag occurs
with reduced knee flexion during early swing. During stance phase the knee remains in 20degrees of
flexion from initial contact through mid stance.
10m walk test: 0.50m/s (limited community ambulation speed)
6min walk test: 395m (572m is norm for age)
Fugl-Meyer Motor Function: UE 45/66 (moderate impairment), LE: 24/34 (mild impairment)
Sample strength testing for determination of 1RM:
During long arc knee extension with a 5 lb cuff weight on the more affected side the patient completed
6 reps with good form but is unable to complete the 7th.
During unilateral leg press the patient can push 15 lbs on the more affected side 20 times and no more,
and 50 lbs on the less affected side 16 times and no more.
Functional strength testing:
Sit to Stand from standard height chair with arm rests (45cm/18inches): accomplishes task without
the use of UEs but with slow movement speed and genu recurvatum of more affected knee at
termination. Patient is able to demonstrate a controlled decent with stand to sit. Pt can repeat this 19
times with good form but unable to complete a 20th rep. 5xSTS test: 12sec (indicates fall risk and
further balance assessment is needed)
Stair climbing: Patient requires UE assist to climb a full flight of stairs with non-reciprocal pattern, left
knee wobble noted
Functional squat (retrieve object from floor): decreased weight acceptance on more affected LE
For the above case please answer the following two questions:
For long arc knee extension and leg press determine the appropriate load, reps, and initial training
parameters. Explain your progression plan:
FPTA Spring Conference 2015: Lower Extremity Strength and Cardiovascular Training in the Post-Stroke
Population: Interpreting and Applying the Evidence
Based on the patient’s functional strength assessment, what other resistance training exercises would
you include: Consider all training modes, training parameters, and a progression plan. Note a rational
for your choices.
CASE 2: A 66 year old female is 3 weeks status post Right ACA ischemic stroke and is being seen in an
inpatient rehabilitation setting. The patient is medically stable. The patient has a history of HTN and
previous MI 6 years prior. The patient completed a cardiac rehab program post MI.
Patient Goals: stand and transfer independently, walk within the home, get stronger
BP: sitting 125/82, Standing 118/77, HTN controlled with Lozol (Indapamide)
Resting HR: 75bpm
Gait: moderate assistance required for 130 feet. The patient can initiate swing but with decreased force
production and assist needed to achieve initial contact. Pt has reduced knee flexion to 30 degrees
during initial swing. Stance phase requires stability assist at both the knee and hip to control against the
effects of gravity.
BERG: 28/56 (high fall risk)
Fugl-Meyer Motor Function: UE 35/66 (moderate impairment), LE: 15/34 (moderate to severe
impairment, able to flex knee and ankle in sitting)
Functional strength testing:
Sit to Stand from standard height chair with arm rests (45cm/18inches): patient accomplishes task with
contact guard to min assist with heavy reliance of the less affected UE and LE throughout the execution
phase. The patient is able to demonstrate a controlled decent with stand to sit but with asymmetrical
limb loading and use of the less affected UE. The patient is unable to complete a 6th repetition without
physical lifting assistance.
Stair climbing: Patient requires UE assist for climbing a 6” step with the more affected LE. Patient is
able to repeat this 4 times with good form and no more.
For the above two functional exercises determine the appropriate load, reps and initial training
parameters. Explain your progression plan:
What other strengthening exercises would you include: Consider all training modes, training
parameters, and a progression plan. Note a rational for your choices.
FPTA Spring Conference 2015: Lower Extremity Strength and Cardiovascular Training in the Post-Stroke
Population: Interpreting and Applying the Evidence
Based on the above Case 1, answer the following questions:
Will you perform and exercise tolerance test? Why or why not? If so, which protocol would you choose?
Calculate the patient’s age predicted max heart rate. Calculate 40%, 65% and 85% max heart rate
values.
Based on this patients current functional status and medical history please provide a plan of care
addressing how you will improve cardiovascular health. Consider all options regarding volume of energy
expenditure, frequency, intensity and duration. Please provide a rationale.
Would you expect to find any limitations in assessing the patient’s response to exercise? If so, how else
can you assess patient’s aerobic effort?
Based on the above case 2, answer the following questions:
Will you perform and exercise tolerance test? Why or why not? If so, which protocol would you choose?
Calculate the patient’s age predicted max heart rate. Calculate 40%, 65% and 85% max heart rate values
Based on this patients current functional status and medical history please provide a plan of care
addressing how you will improve cardiovascular health. Consider all options regarding volume of energy
expenditure, frequency, intensity and duration. Include mode of training. Please provide a rationale.
BORG Scale
0-10
<5
5-6
7-8
% HR max
<64%
64-76%
77-93%
60-84%
3.0-5.9
>/= 6.0
Moderate
Vigorous
40-59%
1.1-2.9
Created by:
Melanie Lomaglio, PT, MSc, NCS
Lindsay Perry, PT, DPT, NCS
<40%
An evidenced based reference tool
for aerobic and resistance training:
risk assessment, screening, and implementation guidelines for physical
therapists.
Low
%HRR
(relative)
METS
(Absolute)
Scientific statement from the
American Heart and Stroke Association (2014).
“Physical Activity and exercise
prescription should be
incorporated into the
management of stroke survivors.
The promotion of physical
activity in stroke survivors
should emphasize low– to
moderate–intensity aerobic
activity, muscle strengthening,
reduction of sedentary behavior,
and risk management for
secondary prevention of
stroke.”1
A clinical
guide to
exercise
prescription
post stroke
Intensity
The benefits of
exercise post
stroke outweigh
the risks1
AHA/ASA/ACSM Resistance
training recommendations1,2
In medically stable patients post stroke, muscle
strengthening and muscle endurance training is
recommended for both in-patient rehab and outpatient rehab settings and it should be offered early.1
In sedentary patients begin with:
WHY Exercise Training?
Secondary prevention of stroke and other CVD
Build aerobic capacity to perform ADL
Improve quality of life and mobility
Begin with 50% 1RM (light intensity)
Progress bi-weekly up to 80% 1RM
Progress to 2-3 sets with 2-3 mins rest
Maintain target load via bi-weekly
assessment of the 1RM
Estimating the 1RM
1 rep = 1 RM
2 reps = .94
3 reps = .91
4 reps = .88
5 reps = .86
6 reps = .83
7 reps = .81
8 reps = .79
9 reps = .77
10 reps = .75
11 reps = .72
12 reps = .70
13 reps = .69
14 reps = .68
15 reps = .66
16 reps = .65
Count number of reps to
failure with a selected weight
(body weight can be used).
From the table select the
corresponding decimal percentage associated with the
number of reps completed.
1 RM = weight lifted / %RM
1 RM x.50 = target load for
sedentary beginner
Structured aerobic exercise programs for stroke
survivors are strongly recommended by level 1
evidence. 1
Build Cardiorespiratory fitness
Volume: 500-1000 METS/week
Reduce depression and social isolation
Intensity: 40-59% HRR for moderate, 6084%HRR for vigorous
1 set of 10-15 reps of 8-10 exercises
2-3 days per week
ASA/AHA Aerobic training
recommendations
Before beginning a physical exercise program that exceeds low intensity (40%HRR),
medical clearance via stress test is recommended. In lieu of a stress test, submax tests
may be considered in the following order:
YMCA/TBRS submax exercise test
6 minute walk test (correlate VO2 max)
Use of BORG RPE scale
Contraindications3
Medical instability of diabetes, angina, arrhythmias
Uncontrolled HRrest, >100 bpm or <50 bpm
Resting Systolic BP >200 mmHg or < 90mmHg
Resting Diastolic BP >110mmHg
Oxygen Saturation < 90%
Duration: 150 min/week at moderate OR
75 min/week at vigorous intensity. **Can
also perform multiple 10 minute bouts**
Frequency: 3-5x/week
Estimating Target HR (THR)
Calculate resting heart rate
Calculate Max HR = 220-age
Heart rate reserve = (% THRX) X
(HRmax—HRrest) + HRrest
References
1. Billinger, SA et al. Stroke. 2014;
45:2532-53.
2. Garber CE et al. Med Sci Sports Exercise. 2011;43:1334-59.
3. Fletcher BJ et al. Cardiac precautions
for non acute inpatient setting. Am. J.
Phys Med Rehabil. 1993. 72:140-143.
AHA/ASA: American Heart Association/
American Stroke Association
ACSM: American College of Sports Medicine
Lower Extremity Strength and Cardiovascular Training in the Post-Stroke
Population: Interpreting and Applying the Evidence
FPTA Spring Conference 2015 – Lomaglio M and Perry L
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