May 2019 Issue
Focus on Fitness: Exercise After Stroke
By Jennifer Van Pelt, MA
Vol. 21, No. 5, P. 52
As many dietitians know, May is National Stroke Awareness Month. Public information campaigns mainly have focused on improving awareness of the signs of stroke and early diagnosis and treatment to minimize poststroke complications and disability. However, more attention needs to be given to increasing awareness of the importance of physical activity after stroke. Although deaths associated with stroke have decreased, poststroke disability has increased—stroke is now the third leading cause of disability. Almost one-half of stroke survivors have a permanent disability. Although exercise can’t address many of the lingering disabilities after stroke, it can improve daily functioning and help prevent additional strokes or other cardiovascular problems. Unfortunately, even high-functioning stroke survivors don’t get enough exercise; research has shown that physical activity of stroke survivors is lower than that of older adults with other chronic health issues.1,2 In 2014, the American Heart Association/American Stroke Association (AHA/ASA) published their Scientific Statement “Physical Activity and Exercise Recommendations for Stroke Survivors,” which summarizes relevant published evidence and provides detailed guidance for health care professionals.1
The AHA/ASA note, “Exercise is a very valuable yet underused component of poststroke care.” Stroke survivors often lead sedentary lives and frequently are deconditioned. As a result, they’re at increased risk of falls, another stroke or other cardiovascular problem, and difficulties with activities of daily living.1 Poststroke problems may vary depending on the type of stroke and the length of time after stroke. Some are resolved with intensive rehabilitation, medications, and other therapies; others are a permanent disability (eg, speech, partial paralysis). However, several poststroke problems, such as chronic pain, depression, fatigue, and issues with mobility, balance, cognitive functioning, and perception, are common to almost all survivors. Over the long term (one to five years after stroke), researchers have found that almost 60% of survivors report problems with mobility, more than 50% report excessive fatigue, and 45% report falls. Appropriate exercise after stroke can help alleviate many of these poststroke issues.1,2
Most stroke survivors undergo prescribed rehabilitation that includes physical activity. However, once prescribed activity ends, according to the AHA/ASA, many stroke survivors, despite being physically capable of regular exercise, choose to remain sedentary. In many cases, stroke survivors don’t realize they can exercise or don’t have access to appropriate exercise due to costs or lack of transportation. Depression, fears (eg, of falls and being injured), fatigue, social anxiety, and other emotional or psychological causes also may contribute to exercise avoidance in stroke survivors. Unfortunately, medical care providers often don’t help stroke survivors identify and address barriers to exercise, leaving this task to the patient and their family or caregivers. For those in long term care settings, physical activity generally is encouraged and easily accessible, as appropriate supervised exercise classes and social events usually are offered regularly to residents. However, for stroke survivors on their own at home, regular exercise may be challenging. The AHA/ASA note that a primary motivating factor for getting stroke survivors to exercise is the potential for socializing with other stroke survivors. Other motivators are participating in guided activities, such as appropriate group fitness classes, and the desire to improve daily functioning related to everyday tasks (eg, being able to clean, care for grandchildren).1
The AHA/ASA recommend the following general guidelines for exercising after stroke1:
• Minimize bed rest.
• Increase daily lifestyle/household activities, such as walking around the house and outside, gardening, vacuuming, and other chores.
• Increase daily exercise based on recovery stage, environment, physical limitations, available social support, and enjoyable activities.
• Do regular aerobic exercise to improve cardiovascular functioning, reduce the risk of recurrent stroke or cardiac events, improve gait and balance, and reduce the risk of falls.
• Perform strength training to increase functioning related to activities of daily living.
• Include flexibility and neuromuscular training in weekly exercise regimens to increase range of motion and balance/coordination, as well as improve mental health and quality of life.
The AHA/ASA also provide more specific guidelines for stroke survivors who have been medically cleared for exercise, including suggested activities, frequency, intensity, and time spent. For aerobic exercise, the AHA/ASA recommends low- to moderate-intensity large-muscle activities such as walking or stationary cycling three or more times per week for 20 to 60 minutes, depending on the individual’s ability. Multiple shorter sessions of 10 to 15 minutes may be more tolerable for some stroke survivors. For strength training, weight-bearing activities, handheld weights, and resistance bands are recommended for all major muscle groups, two to three days per week with one to three sets of 10 to 15 repetitions for each exercise performed. Stretching of all major muscle groups performed after aerobic and/or strength training is recommended. Neuromuscular training should be performed two to three days per week to complement other exercise and improve balance, mobility, and safety during activities of daily living. The AHA/ASA note that yoga; tai chi; modified recreational activities with paddles, balloons, and sport balls; and active-play interactive video/computer gaming (“exergames”) are all appropriate neuromuscular exercises for stroke survivors.1 A 2018 analysis found that exergames also improved both cognitive and motor functioning in patients with poststroke hemiparesis (weakness on one side of the body).3
Getting stroke survivors to start and keep exercising is challenging. For clients medically cleared for exercise after stroke, the following may help them overcome any barriers and motivate them to start a regular exercise program:
• Counsel clients about the benefits of regular physical activity after a stroke.
• Encourage more “around-the-house” activities, such as cleaning and gardening, to get clients used to moving more and improving daily functioning.
• Ask them about their favorite activities to help them select exercises they enjoy. If their favorite activities are sedentary, try to brainstorm ways to incorporate physical activity, such as adding exercise while watching a favorite TV program or joining a walking book club.
• Help them identify barriers to exercise, such as lack of transportation, that may be more easily overcome than fears. Perhaps a friend or family member can drive them to an exercise class or take them mall-walking. Or, there may be free or low-cost community transportation options, such as shuttle buses.
• Investigate local appropriate exercise options for stroke survivors, such as community facilities and gyms that offer Silver Sneakers or Silver & Fit exercise classes, aquatic exercise, chair exercise, gentle yoga, or tai chi. Provide clients with a list to help them find an activity as well as social support in the community.
• Ask clients whether younger family members have exergaming systems, such as the Nintendo Wii, and involve them in helping stroke survivors start exercising at home with these systems.
• Help them keep track of their exercise progress, noting improvements and goals attained, to provide motivation for continued physical activity.
— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.
1. 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(8):2532-2553.
2. Saunders DH, Greig CA, Mead GE. Physical activity and exercise after stroke: review of multiple meaningful benefits. Stroke. 2014;45(12):3742-3747.
3. Mura G, Carta MG, Sancassiani F, Machado S, Prosperini L. Active exergames to improve cognitive functioning in neurological disabilities: a systematic review and meta-analysis. Eur J Phys Rehabil Med. 2018;54(3):450-462.