1. Cardiac Rehabilitation for Stroke Patients Dina Brooks, Associate Professor University of Toronto

2. Is it really survival of the fittest?

3. 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

4. Physical impairments  Weakness  Reduced range of motion  Sensory changes  Altered muscle tone  Impaired coordination  Reduced exercise capacity/fitness level

5. 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

6. Functional ambulation The capacity to execute safe, efficient walking within time and environmental constraints encountered in everyday life Functional Ambulation Sensorimotor Control Fitness

7. Cardiorespiratory and walking deficits may mutually reinforce one another Impaired walking Reduced cardiorespiratory fitness Limits activity Sedentary lifestyle Further weakness  mechanical efficiency  metabolic costs HEALTH RELATED QUALITY OF LIFE Implications for function

8. In addition…..  75% with history of heart disease  50 - 84% have high blood pressure  40% have severe coronary artery disease

9. Stroke risk factors Hypertension Smoking Diabetes Carotid stenosis Atrial fibrillation High cholesterol Obesity Physical Inactivity Risk of second stroke or heart attack

10. Cardiovascular event Cardiac Rehab -Up to 12 months -Supervised exercise program -Education -Nutritional Support Stroke Rehab -? 1-2 months -Functional recovery -Little exercise training -Little formal education

11. Fitness in stroke: What does the literature say?  Exercise program feasible in stroke  Results in: o improved fitness level o reduced neurological impairment o enhanced lower extremity function  Changes in fitness levels from 8 to 23%  Not uniform effect throughout the groups

12. 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?

13. Cardiac rehabilitation model Cardiac Rehab  Up to 12 months  Supervised exercise program  Education  Nutritional Support

14. Effects of Cardiac Rehabilitation for Individuals Following Stroke Heart & Stroke Foundation of Ontario Stroke Rehabilitation Special Competition #SRA 5977

15. 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

16. Design Before and after experimental design with baseline period Participants  Community-dwelling stroke survivors  > 3 months post stroke  Mild to moderate impairment

17. Design Cardiac Rehab programBaseline 3 months 6 months Test 1Test 2Test 3Test 4

18. Outcomes  Maximal exercise test  Semi-recumbent cycle ergometry  VO 2 peak Peak Work Rate Peak Heart Rate  6-Minute Walk Test (6MWT)  Stroke Impact Scale (SIS)  Risk factor profile  Community reintegration

19. Intervention – Cardiac Rehab  Aerobic training 4-5 days / week Resistance training 2 days / week  Education sessions  Training once a week at Centre  Exercise diary

20. 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.

21. Preliminary results Participant Demographics - All n=43 completed Baseline testing Men / Women30 / 13 Age64 ± 13 (38-86) Months post stroke30 ± 28 (3-120) Type: Isch / Hemorr / Unknown28 / 10 / 5 R / L / Bilat hemisphere affected16 / 25 / 2

22. Preliminary results Changes during 3-month baseline period (n=34) 0 months3 monthsp VO 2 peak, ml  kg - 1  min -1 13.1 ± 4.814.9 ± 5.5 NS Peak work rate, watts 59.9 ± 3061.3 ± 33 NS Peak heart rate, beats/min 110.8 ± 21116 ± 23 NS 6-Minute Walk Test distance, 267.9 ± 135273.9 ± 122 NS

23. Preliminary results Changes following program completion (n=27) 0 months3 months VO 2 peak, ml  kg - 1  min -1 14.9 ± 5.516.6 ± 5.5 Peak work rate, watts 61.3 ± 3361.6 ± 31.9 Peak heart rate, beats/min 116 ± 23114 ± 23 6-Minute Walk Test distance, 273.9 ± 132299.4 ± 145.8

24. 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

25. Preliminary results  Subjects extremely satisfied with the program and wish to continue  Adaptation required for the program  Partners satisfied and wish to participate

26. 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

27. 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!

28. Impact on the community  It is time that we start using an established and common model of care (cardiac rehabilitation) in individuals with stroke

29. 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!

30. Acknowledgements  Toronto Rehabilitation Institute Neuro Rehab and Cardiac Rehab Programs for their ongoing support and assistance

31. 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

32. Thank you! Questions, comments… Dina Brooks PhD dina.brooks@utoronto.ca

33. Fitness in Community for Chronic Stroke

34. 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.

35. Methods  Cross-sectional descriptive study  Questionnaire was distributed to 784 fitness facilities in the GTA asking

36. 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

37. 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.