Strength and Cardiovascular Training PostStroke: Applying the Evidence
6/11/2016
Disclosure
Strength and Cardiovascular
Training Post-Stroke:
• No relevant financial relationship exists
Applying the Evidence, Part 1of 2
Melanie Lomaglio, PT, MSc, NCS
Lindsay Perry, DPT, NCS
University of St Augustine for Health Sciences
Part 1 Learning Objectives
• After completing this session, you will be able to:
– Describe the mechanical and neurological components of
muscle force generation pre and post stroke.
– Explain the relationships between muscle strength,
functional performance, capacity, and capability.
– Describe how to appropriately dose and progress a
strength training program using various modes of
exercise
– Evaluate examination data to develop, demonstrate, and
progress appropriately dosed strength training programs
for individuals with stroke across the continuum of care
Rational for session
Course Outline Part 1 and 2
Introduction
• Provide a rational for our topic selection
Part 1: 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 2: Cardiovascular Training
•
•
•
•
•
Differentiate between Physical Activity and Exercise
Assessment of the Cardiorespiratory system
Identify challenges of implementing an aerobic program
AHA/ASH recommendations
Clinical cases/Discussion
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)
 There is strong evidence for low to moderate intensity
muscle strengthening and aerobic activity
 However resistance and aerobic exercise is underutilized
and under dosed
Property of Lomaglio M and Perry L, not to be
copied without permission
1
Strength and Cardiovascular Training PostStroke: Applying the Evidence
6/11/2016
Weakness following stroke
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
• Impaired central motor drive
• Impaired rate coding/reduced firing rates
Excessive motor unit recruitment and fatigue
• Abnormal co-contraction
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, Cooke et al. 2010, Fernandez-Gonzalo et
al. 2014…..)
Weakness following stroke
• Shorter and stiffer muscle fibers
– Fewer sarcomeres, infiltration of connective
tissue
Passive restraint on agonist
For a review refer to:
Gray et al., 2012
• Relative preservation of eccentric torque
occurs bilaterally (Eng et al., 2009)
• Concentric torque-velocity curve altered
– With increasing speed, paretic limb torque
decreases (40-60%) at a greater rate than the
nonparetic side (10-15%)(Patten 2004)
– Reduced Power
• Isometric torque-angle curves altered
– Exaggerated weakness at short muscle lengths
Active restraint on agonist
• Narrowed firing thresholds
• Type II fiber atrophy
• Bilateral weakness exists
For a review refer to:
Gray et al., 2012
Descriptive research suggests:
•
•
•
•
Passive stretching to prevent stiffness
Prevent atrophy via strength training
Strengthen paretic muscles over short lengths
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
(Lomaglio and Eng 2008)
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)
• 2-3 days/week
• Rest ≥48hrs
Gradual progression to:
• 2-4 sets
• Rest 2-3mins between
• 60-70% of 1RM for novice to intermediate (moderate)
• ≥ 80% of 1RM for experienced (hard)
• < 50% 1 RM and 15-20 reps for endurance
Property of Lomaglio M and Perry L, not to be
copied without permission
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
• Programs should be developed by trained
professionals and should be offered early after stroke
Note: There are no protocols to guide activity prescription in the
first 48 hours post stroke but strengthening is recommended for
in-patient and out-patient as soon as the patient is medically
stable
2
Strength and Cardiovascular Training PostStroke: Applying the Evidence
CDC: Older adult recommendations:
NOT supervised
http://www.cdc.gov/physicalactivity/basics/ol
der_adults/index.htm. accessed Apr 27, 2016.
• ≥ 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
– 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)
Calculating 1 RM indirectly with
submax estimate calculators
http://www.exrx.net/
Calculators/OneRepMax.html
Note: reps must be b/w 1 and 10
 Apps for smart phones
can also be used
6/11/2016
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 comorbidities
• Assess vitals
• Assess BP before
– Supine, sitting, standing
Calculating 1RM with coefficients
Example:
Your patient can perform 5 good reps (and no
more) at 35 lbs. for paretic leg press.
1 RM ≈ weight lifted / %RM (i.e. coefficient)
1 RM ≈ 35 / .856 = 41 lbs
Start patient at 50% 1RM (light intensity)
41lbs x 50% ≈ 20 lbs
1 set of 10-15 reps, 2-3 days / week
Re-check in 2 weeks and progress weight (± sets)
http://www.timinvermont.com/
fitness/orm.htm
Estimating 1RM with 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 / 0.75 1RM ≈ wt lifted / % 1RM (i.e. coefficient)
1 RM ≈ 9 lbs
Now you can select whatever % is appropriate for training
Property of Lomaglio M and Perry L, not to be
copied without permission
Successful & Safe PRT RCT protocols
Ouellette et al. 2004; chronic
• 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
All subjects were mild to moderate in
severity and were independent
ambulators with or without a device
Flansbjer et al., 2008; chronic
• 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
• Intensity increased bi-weekly
• Stretching to cool down
3
Strength and Cardiovascular Training PostStroke: Applying the Evidence
Power training: explosive
resistance training
Eccentric Training
• Relative preservation (thus can train at
higher more potent loads)
• Unique activation strategy
• Fernandez-Gonzalo 2014 and 2016 (RCT)
– 4 sets of 7 reps (2min contractile activity),
2x/wk for 12wks
– Increased power, force, size, balance and TUG
• Clark and Patten 2013
Fast concentric phase, slow eccentric
• Addresses alerted torque-velocity curve
• Fall prevention, gait speed/forward
progression
– Start at a lower intensity and progress (Puthoff
Eccentric Overload flywheel
leg press (Fernandez-Gonzalo
et al. 2014 and 2016)
Isokinetic dynamometer
(Clark and Patten 2012)
– 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
Kieser air leg press
machine
Functional Training
Power training
Morgan et al (2015), single group design:
• 3x/wk for 8 wks, 2-3 sets of 8-15 reps
• Unilateral Leg press, calf raises and
jumping on Shuttle MVP, + walking
practice at 125% of SSWS
Shuttle MVP trainer
CSM 2015)
– 3x per week for 5 weeks, + gait training
– hip, knee and ankle at 30-120d/s
– Increased power and gait speed
• Cross transfer to nonparetic, untrained leg
• No superior benefit over other training
modes have been demonstrated yet but
carry over to function looks promising
6/11/2016
• Repeated standing up and sitting
down
Shuttle MVP trainer
– Significant increased strength, power and
gait speed
• Also promising in the paretic UE (Patten
et al. 2013) and older adult for improving
functional performance (Sayers 2007)
– 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
Consider a weighted vest for
adding resistance
– Ex: trailing leg position with theraband
Functional Strength Training (FST)
• Limited research on functional progressive repetitive training
• Cooke et al. (2010) compared 109 patients with acute stroke:
CPT vs CPT+FST vs CPT+CPT for 6 weeks
• Both extra therapy groups (+1hr) showed greater improvement
in gait speed compared to control, only the CPT+CPT was
significant
• No group differences for strength
SAMPLE FST:
• 5 reps of STS from 40 ◦, once 5 sets of 10 achieved the ht was lowered
• Stair climbing similar protocol
• Other activities included transfer training, gait and BWSTT
• Kerr et al. (in press 2016) follow up report demonstrated no
between group differences on STS performance
Property of Lomaglio M and Perry L, not to be
copied without permission
Cross Education of strength from
less-affected to more affected side
• Gragert and Zehr (2013) reported a 31% increase in
torque in the more affected untrained dorsiflexors and
a 35% in the less-affected trained dorsiflexors after
isometric training
Implications for the severely weak
Interested? See Ehrensberger M et al. (2016): systematic review
4
Strength and Cardiovascular Training PostStroke: Applying the Evidence
Other considerations for the severely weak
(<3/5)
• Open-chain exercise
• Eccentric training
• Electrical-stim with or without voluntary
contraction
• Biofeedback
• Mental imagery
Ada et al., 2006
Do improvements in strength cause
improvements in function?
• There is conflicting evidence that changes in strength result
in improvements in ADL performance, distance walked or gait
speed (refer to ebrsr.com for a review)
Systematic reviews also conflict:
• Pak and Patten 2008: +ve strength, + function, + participation
• Morris et al 2004: +ve strength, –ve function
• Ada et al 2006*: +ve strength, + function
• Salter et al. 2016: - strength, -ve function (not recommended
in first 3 months but likely safe; more research needed)
6/11/2016
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 nonexistent”
• Falls
• Valsalva / transient HTN
• Delayed onset muscle soreness (DOMS)
Possible explanations:
• Acute vs chronic
– PRT is different than task specific training
– Under dosing / fear of harm
• 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)
A: change in
strength will not
improve gait
B: change in
strength will
improve gait speed
*Ada et al., 2006 included studies with mental imagery, biofeedback and
muscle re-education repetitive training and acute stroke
Buchner et al. 1996
Other considerations:
Capacity and Capability via
Multi-modal Exercise
• Prevent atrophy and
increase strength
• Increase physical fitness
• Reduce osteoporosis
• Reduce fatigue
• Decrease cardiovascular risk
• Increase mobility
• Reduce depression and
social isolation
• Strength, endurance, and
possibly power training for
fall prevention
• Aerobic
• Circuit Training
• Flexibility
• Neuromuscular (balance
coordination)
• Functional training
Billinger et al., 2014
Property of Lomaglio M and Perry L, not to be
copied without permission
C: Not strong
enough to walk
Key References and Resources
Full list available in handouts
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/basics/older_adults/index.htm, accessed Apr 27, 2016
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.
• Salter K, Muscovic A, Taylor N. In the first 3 months after stroke is progressive resistance
training safe and does it improve activity? A systematic review. Top Stroke Rehabil.
2016;23:1-10. DOI: 10.1080/10749357.2016.116-656.
• Evidenced-Based Review of Stroke Rehabilitation: www. ebrsr.com
5
Strength and Cardiovascular Training PostStroke: Applying the Evidence
Clinical Cases / Lab / Discussion
6/11/2016
CASE 1: A 65 yo male referred to outpt PT 6 mo post R MCA stroke. History of 2 falls and HTN.
Pt reports a sedentary lifestyle since stroke. MD clearance for vigorous exercise.
BP: sitting 135/87, Standing 133/85, HTN controlled with Atenolol Resting HR: 75bpm
Gait: mod I with SPC for household distances. Mod I with SPC on level terrain, supervision / min
A for curbs. During swing, intermittent foot drag occurs with reduced knee flexion during early
swing. During stance the knee remains in 20d of flex from IC to thru mid stance
10m walk test: 0.50m/s, 6min walk test: 395m
Fugl-Meyer Motor Function: UE 45/66, LE: 24/34
Sample strength testing for determination of 1RM:
During LAQ with a 5 lb cuff weight on the more affected side the patient completed 6 reps 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:
Brooks Rehab Jacksonville FL, YMCA stroke wellness
program
Sit to Stand (18in chair): mod I without UE’s, slow, genu recurvatum at termination. Pt can do
this 19x with good form (and no more)
Stair climbing: Pt requires UE assist to climb a full flight, L knee wobbles
Retrieve object from floor (squat): decreased wt acceptance on more affected LE
Determine load, reps, initial training parameters, and progression for LAQ and leg press
Based on the clinical findings, what other resistance training would you use?
CASE 2: A 66 yo female is 3 weeks status post Right ACA stroke and is being seen in an inpt
rehab. 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.
BP: sit 125/82, Stand 118/77, HTN controlled with Lozol (Indapamide),Resting HR: 75bpm
Gait: modA for 130 ft. The pt can initiate swing but with decreased force production and
assist for initial contact. Pt has reduced knee flexion to 30 d during initial swing. Stance
requires stability assist at both knee and hip.
BERG: 28/56 (high fall risk) Fugl-Meyer Motor Function: UE 35/66, LE: 15/34
Functional strength testing:
Sit to Stand (18in chair): pt accomplishes task with CGA to MinA with heavy reliance of the
less affected UE & LE throughout. The patient is unable to complete a 6 th 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.
Determine load, reps, initial training parameters, and progression for STS and stair climbing
Based on the clinical findings, what other resistance training would you use?
Property of Lomaglio M and Perry L, not to be
copied without permission
6