Comprehensive Cardiac Rehabilitation for Secondary Prevention After Transient Ischemic Attack or Mild Stroke

Interventions That Support Lifestyle Behavior Change for Secondary Prevention of Stroke: A Scoping Review

Lifestyle behavioral change is a critical component for secondary prevention of stroke. Although evidence for the effectiveness of lifestyle behavior change is growing, methods to promote and maintain behavior change remain unclear. In this review, we aimed to synthesize the evidence for lifestyle behavior change interventions among patients living with stroke or transient ischemic attack. We searched 7 databases to identify studies, including randomized controlled trials, quasi-experimental, and longitudinal studies examining changes in cardiovascular risk factors. Data were extracted regarding participant characteristics, intervention attributes (eg, provider, behavior change techniques, and modality), and effectiveness for control of risk factors. From 4620 records identified, 73 studies were included. Information about the type of behavior change theory applied was reported in 36% of studies. The social cognitive theory and transtheoretical models were the most commonly cited frameworks. Changes in physical activity (64%) and blood pressure (63%) were the most frequently assessed outcomes. Fewer than half of the studies assessed changes in weight (41%), blood cholesterol (40%), diet (36%), smoking cessation (33%), alcohol consumption (19%), and blood glucose (18%). No studies assessed sleep as a risk factor. Most studies had mixed effects or no change for the risk factor measured. No studies reported negative effects. Interventions associated with improvements were more commonly delivered by a multidisciplinary team and informed by behavior change techniques. Further research is required to identify the most effective methods to promote and sustain lifestyle behavior change among people living with stroke or transient ischemic attack.

Association between lower extremity physical function and physical activity after ischemic stroke: Longitudinal findings from the MOBITEC-Stroke project

Background

Stroke often results in physical impairments. Physical activity is crucial for rehabilitation, enhancing mobility, strength, and overall health. This study examines the association between Timed Up-and-Go (TUG) test performance and changes in physical activity to improve lower extremity physical function.

Methods

The MOBITEC-Stroke Cohort Study ("Recovery of mobility function and life-space mobility after ischemic stroke") included patients with a first incidence of stroke. Data assessed 3 and 12 months after stroke were used for analysis. Linear regression model adjusted for age, sex, instrumental activities of daily living, Falls Efficacy Scale-International, modified Ranking Scale, and National Institutes of Health Stroke Scale-score was used to examine the relationship between lower extremity physical function (i.e., TUG) and change in physical activity (i.e., minutes of physical activity measured with a wrist-worn accelerometer over 1 week).

Results

Longitudinal data of 49 patients (65% male, mean age 71.2 (SD: 10.4) years) were analyzed. Mean daily physical activity was 291.6 (SD: 96.2) min at 3 months and 298.9 (SD: 94.4) min at 12 months, with a change from 3 to 12 months of 7.3 min (95% CI: -9.4 to 24.0; p = 0.394) post-stroke. We observed significant relationships between the baseline TUG performance and the change in total physical activity over 9 months (p = 0.011) and between the change of TUG performance over time and the change in total physical activity (p = 0.022).

Conclusion

Our findings indicate that better initial lower extremity physical function and higher improvements in function over time are associated with a greater increase in physical activity levels after stroke. This suggests that interventions aimed at maintaining and improving lower extremity physical function may positively affect physical activity levels.

Mechanisms and benefits of cardiac rehabilitation in individuals with stroke: emerging role of its impact on improving cardiovascular and neurovascular health

Human and animal studies have demonstrated the mechanisms and benefits of aerobic exercise for both cardiovascular and neurovascular health. Aerobic exercise induces neuroplasticity and neurophysiologic reorganization of brain networks, improves cerebral blood flow, and increases whole-body VO2peak (peak oxygen consumption). The effectiveness of a structured cardiac rehabilitation (CR) program is well established and a vital part of the continuum of care for people with cardiovascular disease. Individuals post stroke exhibit decreased cardiovascular capacity which impacts their neurologic recovery and extends disability. Stroke survivors share the same risk factors as patients with cardiac disease and can therefore benefit significantly from a comprehensive CR program in addition to neurorehabilitation to address their cardiovascular health. The inclusion of individuals with stroke into a CR program, with appropriate adaptations, can significantly improve their cardiovascular health, promote functional recovery, and reduce future cardiovascular and cerebrovascular events thereby reducing the economic burden of stroke.

Integrating Cardiac Rehabilitation in Stroke Recovery

Stroke remains a top contributor to long-term disability in the United States and substantially limits a person's physical activity. Decreased cardiovascular capacity is a major contributing factor to activity limitations and is a significant health concern. Addressing the cardiovascular capacity of stroke survivors as part of poststroke management results in significant improvements in their endurance, functional recovery, and medical outcomes such as all-cause rehospitalization and mortality. Incorporation of a structured approach similar to the cardiac rehabilitation program, including aerobic exercise and risk factor education, can lead to improved cardiovascular function, health benefits, and quality of life in stroke survivors.

Is early initiated cardiorespiratory fitness training within a model of stroke-integrated cardiac rehabilitation safe and feasible?

OBJECTIVE

To investigate the safety and feasibility of an early initiated stroke-integrated Cardiac Rehabilitation program.

METHODS

People with acute first or recurrent ischaemic stroke, admitted to Epworth HealthCare were screened for eligibility and invited to participate. In addition to usual care neurorehabilitation, participants performed 1) cardiorespiratory fitness training 3-days/week during inpatient rehabilitation (Phase 1), and/or 2) 2-days/week centre-based cardiorespiratory fitness training plus education and 1-day/week home-based cardiorespiratory fitness training for 6-weeks during outpatient rehabilitation (Phase 2). Safety was determined by the number of adverse and serious adverse events. Feasibility was determined by participant recruitment, retention, and attendance rates, adherence to exercise recommendations, and participant satisfaction.

RESULTS

There were no study-related adverse or serious adverse events. Of 117 eligible stroke admissions, 62 (53%) were recruited, while 10 (16.1%) participants withdrew. Participants attended 189 of 201 (94%) scheduled cardiorespiratory fitness training sessions in Phase 1 and 341/381 (89.5%) scheduled sessions in Phase 2. Only 220/381 (58%) scheduled education sessions were attended. The minimum recommended cardiorespiratory fitness training intensity (40% heart rate reserve) and duration (20 minutes) was achieved by 57% and 55% of participants respectively during Phase 1, and 60% and 92% respectively during Phase 2. All respondents strongly agreed (69%) or agreed (31%) they would recommend the stroke-integrated Cardiac Rehabilitation program to other people with stroke.

CONCLUSION

Cardiorespiratory fitness training in line with multiple clinical practice guidelines included within a model of stroke-integrated Cardiac Rehabilitation appears to be safe and feasible in the early subacute phase post-stroke.

Sex differences and predictors of completion of a 6-month exercise-based cardiac rehabilitation program in 1,536 people following stroke

OBJECTIVE

To retrospectively examine sex-differences and predictors of completion in consecutively-referred patients to a 6-month exercise-based cardiac rehabilitation program (CRP) from 2006 to 2017.

MATERIALS/METHODS

People with hemiplegic gait participated in stroke-adapted-CRP; otherwise, traditional-CRP. Reasons for non-completion were ascertained by interview. Regression-analyses were conducted to determine non-completion in all patients and women and men separately.

RESULTS

There were 1536 patients (30.3% women), mean age 64.5 ± 12.5 with 23% initiating the stroke-adapted-CRP. Overall, 75.1% completed the CRP (87.3% stroke-adapted-CRP vs 71.5% traditional-CRP; p < .001). There was no difference in completion between women and men (74.5% vs 75.4%; p=0.7), or in attendance to pre-scheduled sessions (p=0.6) or reasons for non-completion (p > .05, all). The only sex difference in completion by age (decade) occurred in those <41 years (59% women vs 85% men; p=.02). Baseline predictors of non-completion among all patients included not being enrolled in the stroke-adapted-CRP, lower V̇O_2peak, smoking, diabetes (prescribed insulin) and depression but not sex (p=.5) or age (p=.15). Unique predictors in women vs men were younger age, lower V̇O_2peak, smoking, diabetes (prescribed insulin), depression, and cancer diagnoses. Unique to men was having >1 stroke and diabetes (any anti-diabetes medication). The strongest predictor of non-completion among all models was not being enrolled in stroke-adapted-CRP.

CONCLUSIONS

While there were no sex-differences in adherence to the CRP, women and men have mostly unique predictors of non-completion. Younger women are at greatest risk for non-completion. Practitioners should provide sex-specific, tailored strategies for enhancing completion with a focus on younger women and offering a stroke-adapted-CRP with close attention to those with diabetes.

Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association

At least 240 000 individuals experience a transient ischemic attack each year in the United States. Transient ischemic attack is a strong predictor of subsequent stroke. The 90-day stroke risk after transient ischemic attack can be as high as 17.8%, with almost half occurring within 2 days of the index event. Diagnosing transient ischemic attack can also be challenging given the transitory nature of symptoms, often reassuring neurological examination at the time of evaluation, and lack of confirmatory testing. Limited resources, such as imaging availability and access to specialists, can further exacerbate this challenge. This scientific statement focuses on the correct clinical diagnosis, risk assessment, and management decisions of patients with suspected transient ischemic attack. Identification of high-risk patients can be achieved through use of comprehensive protocols incorporating acute phase imaging of both the brain and cerebral vasculature, thoughtful use of risk stratification scales, and ancillary testing with the ultimate goal of determining who can be safely discharged home from the emergency department versus admitted to the hospital. We discuss various methods for rapid yet comprehensive evaluations, keeping resource-limited sites in mind. In addition, we discuss strategies for secondary prevention of future cerebrovascular events using maximal medical therapy and patient education.

Exercise prescription, intervention, dissemination, and implementation following transient ischemic attack or stroke: advancing the field through interdisciplinary science

Research has demonstrated that both exercise, and a reduction in cardiovascular disease (CVD) risk factors (i.e., high blood sugar, blood lipids, and blood pressure), following a stroke or transient ischemic attack (TIA) are beneficial for reducing risk of recurrent stroke or TIA and for improving overall quality of life. Despite this evidence, many stroke and TIA survivors remain inactive and sedentary and present with multiple CVD risk factors. The purpose of this commentary is to highlight gaps in the current literature in regard to exercise and behavior interventions for the stroke and TIA populations, present ideas for intervention design, and discuss the dissemination and implementation of research findings. The future research ideas presented in this commentary are based on current research findings, as well as the professional experience of the article authors. Professional experience spans occupational therapy in neurorehabilitation, clinical exercise physiology in rehabilitation, creation and implementation of stroke rehabilitation clinics, stroke and TIA research, and behavioral and implementation science.

Addition of high-intensity interval training to a moderate intensity continuous training cardiovascular rehabilitation program after ischemic cerebrovascular disease: A randomized controlled trial

Introduction

Moderate intensity continuous training (MICT) is usually recommended for stroke or transient ischemic attack (TIA) patients. High intensity interval training (HIIT) has emerged as a potentially effective method for increasing cardiorespiratory fitness (CRF) among clinical populations. Its effectiveness remains to be demonstrated after stroke. A combined program of HIIT and MICT was designed to create a realistic exercise program implemented for a clinical setting to help patients become more active.

Purpose

This study aimed to compare the effects of a 6-month exercise program with either MICT only or a combination of HIIT and MICT and a control group in terms of CRF, cardiovascular risk factors, functionality, cognitive function (Montreal Cognitive Assessment) and depression markers (Hospital Anxiety and Depression Scale).

Methods

This randomized controlled trial started with 52 participants (33 men and 19 women, mean age: 69.2 ± 10.7) divided into three groups: HIIT + MICT combined, MICT, and control. Both exercise groups consisted of 4 weekly sessions including supervised and at-home exercise. Outcomes were assessed at T0 (baseline measure), T6 (end of exercise protocols), and T12 (follow-up), 40 participants having completed the 12-month follow-up.

Results

At T6, both HIIT+MICT and MICT programs provided a similar increase of CRF (3 ml·min-1·kg-1) from baseline (p < 0.01), while the control group showed a global slight decrease. Despite some decrease of CRF at T12 compared to T6, improvement persisted 6 months post-intervention (HIIT + MICT: p < 0.01 and MICT: p < 0.05). The control group decreased compared with baseline (p < 0.05). The two exercise programs induced a comparable increase in self-reported physical activity and a decrease in anxiety and depression markers. Participants in HIIT + MICT and MICT programs declared a good degree of acceptability assessed by the Acceptability and Preferences Questionnaire.

Conclusion

A 6-month HIIT + MICT combined program and a standard MICT program induced similar improvements in CRF, self-reported physical activity and anxiety and depression markers among patients with prior ischemic stroke or TIA compared with a control group. These effects appear to persist over time. Addition of HIIT was safe and considered acceptable by participants. Our results do not support any superiority of the combination HIIT + MICT nor disadvantage vs. MICT in this population.

Cardiovascular Rehabilitation for transient ischaemic Attack and Mild Stroke: the CRAMS effectiveness-implementation hybrid study protocol

BACKGROUND

Internationally, stroke and cardiac rehabilitation clinicians agree that current cardiac rehabilitation models are a suitable secondary prevention program for people following a transient ischaemic attack (TIA) or mild stroke. There is strong evidence for exercise-based cardiac rehabilitation in people with heart disease, however, the evidence for cardiac rehabilitation post-TIA or stroke is limited. Here we will explore the effectiveness and implementation of an integrated (TIA, mild stroke, heart disease) traditional exercise-based cardiovascular rehabilitation (CVR) program for people with TIA or mild stroke over 6-months.

METHODS

This type 1 effectiveness-implementation hybrid study will use a 2-arm single-centre assessor-blind randomised controlled trial design, recruiting 140 participants. Adults who have had a TIA or mild stroke in the last 12-months will be recruited by health professionals from hospital and primary healthcare services. Participants will be assessed and randomly allocated (1:1) to the 6-week CVR program or the usual care 6-month wait-list control group. Distance completed in the 6-min walk test will be the primary effectiveness outcome, with outcomes collected at baseline, 6-weeks (complete CVR) and 6-months in both groups. Other effectiveness outcome measures include unplanned cardiovascular disease-related emergency department and hospital admissions, daily minutes of accelerometer moderate-to-vigorous physical activity, body mass index, waist circumference, blood pressure, quality of life, anxiety and depression. Implementation outcomes will be assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, including a cost-effectiveness analysis. Semi-structured interviews will be conducted with participants and CVR program health professionals, investigating the acceptability, value, and impact of the CVR program. Qualitative analyses will be guided by the Consolidated Framework for Implementation Research.

DISCUSSION

Few studies have assessed the effectiveness of cardiac rehabilitation for people with TIA and mild stroke, and no studies appear to have investigated the cost-effectiveness or implementation determinants of such programs. If successful, the CVR program will improve health outcomes and quality of life of people who have had a TIA or mild stroke, guiding future research, policy, and clinical practice, reducing the risk of repeat heart attacks and strokes for this population.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621001586808 , Registered 19 November 2021.

The effect of the Mediterranean diet on health outcomes in post-stroke adults: a systematic literature review of intervention trials

BACKGROUND

Stroke represents a major source of mortality and morbidity worldwide. Guidelines for stroke management and secondary prevention focus on reducing stroke-related risk factors such as smoking cessation, exercise and diet. Several clinical practice guidelines specifically recommend a Mediterranean diet (MD) for individuals with stroke. However, these recommendations rely primarily on observational research. The aim of this review is to critically appraise the current experimental evidence assessing the use of a Mediterranean diet on health outcomes in post-stroke adults.

METHODS

A systematic literature review was conducted of original research which assessed the role of a Mediterranean diet on health outcomes in post-stroke adults. The following databases were searched: PROQUEST, SCOPUS (Elsevier), MEDLINE (EBSCO), EMBase and Cochrane Library up to the 25th of August 2021.

RESULTS

A total of 6 studies from a total of 5838 identified studies met the full inclusion criteria and were included in this review. Several different health outcomes were assessed, including blood pathology tests, physical examinations, secondary vascular events and mortality. The Mediterranean diet appears to be beneficial for systolic and diastolic blood pressure, LDL cholesterol, BMI and waist circumference.

CONCLUSION

This review suggests a Mediterranean diet may be helpful for several health outcomes in post-stroke adults. However, more research is needed to confirm these findings. To ensure robust methodology and replication of results, specific details of the included and excluded foods, quantities and serving sizes should be reported in future research.

Perspectives and Experiences of Cardiac Rehabilitation after Stroke—A Qualitative Study

Cardiac rehabilitation (CR) after stroke has been proven to be a safe and feasible secondary prevention intervention. Limited qualitative data capture people’s experiences and perceptions of attending CR following stroke, but with none addressing translational aspects when CR is delivered as routine clinical care. Using a phenomenological, qualitative approach, four semi-structured focus groups were conducted with 15 individuals (60% male) who had completed CR during their stroke care pathway. Our inductive thematic analysis identified five themes. The first centred on recognising stroke as a cardiovascular disease and the applicability of CR post-stroke. The second addressed how peer understanding, camaraderie, and medical supervision created a safe and supportive environment. The third identified how the programme-built confidence supported longer-term healthy lifestyle choices in physical activity, diet, and smoking. The penultimate theme addressed the period from hospital discharge to attending CR as a time of uncertainty where many participants experienced cognitive difficulties, mood disturbances, and mental fatigue without adequate support. Lastly, participants identified unmet needs in their care pathway that included a lack of information about their referral to CR, the programme content, and accessing local supports ahead of CR. Ongoing and unmet needs both during and after CR related to self-management of secondary prevention medications, neurological issues, post-stroke fatigue, and the lack of structured support following CR completion.

Normobaric Hypoxia Exposure During Treadmill Aerobic Exercise After Stroke: A Safety and Feasibility Study

Objective

To evaluate the safety and feasibility of performing treadmill aerobic exercise in moderate normobaric hypoxia among chronic hemiparetic stroke survivors.

Design

Observational study using convenience sampling.

Setting

Research laboratory in a tertiary rehabilitation hospital.

Participants

Chronic hemiparetic stroke survivors who could walk at least 10-m with or without assistance and had no absolute contraindications to exercise testing.

Intervention

Participants (three male and four female) were asked to complete three normobaric hypoxia exposure protocols within a single session. First, they were passively exposed to normobaric hypoxia through gradual reductions in the fraction of inspired oxygen (F_IO₂ = 20.9, 17.0, and 15.0%) while seated (5-min at each level of F_IO₂). Participants were then exposed to the same reductions in F_IO₂ during constant-load exercise performed on a treadmill at 40% of heart rate reserve. Finally, participants completed 20-min of exercise while intermittently exposed to moderate normobaric hypoxia (5 × 2-min at F_IO₂ = 15.0%) interspaced with 2-min normoxia intervals (F_IO₂ = 20.9%).

Outcome Measures

The primary outcome was occurrence of adverse events, which included standardized criteria for terminating exercise testing, blood oxygen saturation (SpO₂) <80%, or acute mountain sickness score >2. The increased cardiovascular strain imposed by normobaric hypoxia exposure at rest and during exercise was evaluated by changes in SpO₂, heart rate (HR), blood pressure, and rating of perceived exertion (RPE).

Results

One participant reported mild symptoms of nausea during exercise in normobaric hypoxia and discontinued participation. No other adverse events were recorded. Intermittent normobaric hypoxia exposure was associated with reduced SpO₂ (MD = −7.4%, CI: −9.8 to −5.0) and increased HR (MD = 8.2, CI: 4.6 to 11.7) compared to intervals while breathing typical room air throughout the 20-min constant-load exercise period. The increase in HR was associated with a 10% increase in relative effort. However, reducing F_IO₂ had little effect on blood pressure and RPE measurements.

Conclusion

Moderate normobaric hypoxia appeared to be a safe and feasible method to increase the cardiovascular strain of submaximal exercise in chronic hemiparetic stroke survivors. Future studies evaluating the effects of pairing normobaric hypoxia exposure with existing therapies on secondary prevention and functional recovery are warranted.

Safety and effectiveness of early cardiac rehabilitation in a stroke patient with heart failure and atrial fibrillation

Stroke patients have reduced aerobic capacity. Therefore, intensive structured exercise programs are needed. We report the case of a patient with stroke and cardiac disease who underwent early inpatient cardiac rehabilitation (CR). A 38-year-old male patient with atrial fibrillation, heart failure, and cerebral infarction underwent a symptom-limited exercise tolerance test (ETT) without any problems on day 45 after admission. He completed a 2-week inpatient program and an 8-week home-based CR program. Follow-up ETT showed increased exercise capacity. The present case might be the first to report a safely performed CR program in a patient with stroke and cardiac comorbidity in Korea. Systematic guidance is needed for post-stroke patients to receive safe and effective CR for the secondary prevention of stroke and cardiovascular risk.

Factors Associated With Non-enrollment of Center-Based Cardiovascular Rehabilitation Program Among Transient Ischemic Attack or Mild Stroke Patients: A MIXED-METHOD RETROSPECTIVE STUDY

PURPOSE

Cardiovascular rehabilitation programs (CRPs) are effective in secondary stroke prevention, yet the enrollment rate is suboptimal. This study aims to identify demographic and clinical factors and patient-reported reasons for non-enrollment in a center-based outpatient CRP among patients with transient ischemic attack (TIA) or mild stroke.

METHODS

This mixed-method retrospective chart review was conducted in an outpatient CRP affiliated with a tertiary care hospital in Canada from January 2009 to October 2017. A total of 621 patients with TIA or mild stroke were included. Multiple logistic regression was used to determine the relationship between demographic and clinical predictors with non-enrollment. A thematic analysis of multidisciplinary progress notes was done for the non-enrollment subgroup of patients to understand the patient-reported reasons.

RESULTS

The non-enrollment rate was 42%. Travel distance to CRP (OR = 1.024; 95% CI, 1.010-1.038), age (OR = 1.023; 95% CI, 1.004-1.042), and current smoking status (OR = 1.935; 95% CI, 1.230-3.042) were associated with non-enrollment. The patient-reported reasons for non-enrollment were occurrence of new medical events and comorbidities, their perceptions of health and CRP, transportation, work/time conflict, and distance.

CONCLUSIONS

This study found that patients with TIA or mild stroke who were older, lived farther from the CRP center, or were current smokers were less likely to enroll in a CRP. The present findings may help clinicians identify patients unlikely to enroll in a CRP and allow the implementation of interventions focused on health education and physical activity to improve enrollment. Future research should validate these factors in multiple settings using prospective mixed methods so that interventions can be developed to address non-enrollment in the CRP.

Inclusion of stroke patients in expanded cardiac rehabilitation services: a cross-national qualitative study with cardiac and stroke rehabilitation professionals

PURPOSE

This qualitative study explored healthcare professionals' views in relation to the potential expansion of cardiac rehabilitation services to include stroke patients, thereby becoming a cardiovascular rehabilitation model.

DESIGN AND METHODS

23 semi-structured interviews were completed with hospital and community-based stroke and cardiac rehabilitation professionals in Switzerland (n = 7) and Ireland (n = 19). The sample comprised physiotherapists, occupational therapists, speech and language therapists, stroke physicians, cardiologists, psychologists, dieticians and nurses. Interviews were audio-recorded and the transcripts were analysed in NVivo using inductive Thematic Analysis.

RESULTS

Barriers and facilitators to cardiovascular rehabilitation were captured under four broad themes; (i) Cardiac rehabilitation as "low-hanging fruit," (ii) Cognitive impairment ("the elephant in the room"), (iii) Adapted cardiac rehabilitation for mild stroke, and (iv) Resistance to change.

CONCLUSIONS

Hybrid cardiac rehabilitation programmes could be tailored to deliver stroke-specific education, exercises and multidisciplinary expertise. Post-stroke cognitive impairment was identified as a key barrier to participation in cardiac rehabilitation. A cognitive rehabilitation intervention could potentially be delivered as part of cardiac rehabilitation, to address the cognitive needs of stroke and cardiac patients.Implications for rehabilitationThe cardiac rehabilitation model has the potential to be expanded to include mild stroke patients given the commonality of secondary prevention needs.Up to half of stroke survivors are affected by post-stroke cognitive impairment, consequently mild stroke patients may not be such an "easy fit" for cardiac rehabilitation.A cardiovascular programme which includes common rehabilitation modules, in addition to stroke- and cardiac-specific content is recommended.A cognitive rehabilitation module could potentially be added as part of the cardiac rehabilitation programme to address the cognitive needs of stroke and cardiac patients.

Integrating Cardiac Rehabilitation with Neurorehabilitation in a Patient with Ischemic Stroke after Cardiac Surgery: a Case Report

Stroke and cardiac disorders are difficult to approach separately. Stroke survivors commonly have cardiovascular comorbidities and vice versa. These patients often need both neurorehabilitation and cardiac rehabilitation; therefore, this is an important issue in the rehabilitation process. However, no consensus has been reached on the integration of cardiac rehabilitation and neurorehabilitation. We report the case of a 52-year-old male patient who had ischemic stroke after mitral valvuloplasty. The patient underwent 3 weeks of inpatient neurorehabilitation, and then transited to 6 weeks of outpatient cardiac rehabilitation and occupational therapy. After 9 weeks of well-integrated rehabilitation, the patient experienced neurologic recovery and improvement in his cardiopulmonary fitness. Like this case, successful integrated rehabilitation will contribute to enhancing patients' functional recovery.

Including Patients With Stroke in Cardiac Rehabilitation: BARRIERS AND FACILITATORS

More than 13 million cases of stroke are occurring annually worldwide. Approximately a quarter of these strokes are recurrent strokes, and there is compelling evidence of the benefit of supervised exercise and risk factor modification programming in the secondary prevention of these strokes. However, there is insufficient time in inpatient and outpatient stroke rehabilitation for focused exercise interventions. General lifestyle interventions on their own, without guidance and supervision, are insufficient for improving physical activity levels. Cardiac rehabilitation (CR) is a setting where cardiac patients, and increasingly stroke patients, receive comprehensive secondary prevention programming, including structured exercise. Unfortunately, not all CR programs accept referrals for people following a stroke and for those that do, only a few patients participate. Therefore, the purpose of this review is to report the barriers and facilitators to improving linkage between health services, with a focus on increasing access to CR. In the next two decades, it is projected that there will be a marked increase in stroke prevalence globally. Therefore, there is an urgent need to create cross-program collaborations between hospitals, outpatient stroke rehabilitation, CR, and community programs. Improving access and removing disparities in access to evidence-based exercise treatments would positively affect the lives of millions of people recovering from stroke.

Physical activity after ischemic stroke and its association with adverse outcomes: A nationwide population-based cohort study

BACKGROUND

Sufficient physical activity (PA) is highly recommended to improve the prognosis after stroke. However, there have been only a few studies evaluating the changes in PA level after stroke.

AIMS

We aimed to identify the changes in PA level between before and after stroke, and to determine the association between PA and adverse outcomes.

METHODS

This observational, retrospective cohort study was performed using  the Nationwide Health Insurance Service (NHIS) database in South Korea. Subjects between the ages of 20 to 80 years, who had a first-ever ischemic stroke from 2010 to 2013, were included. Subjects were divided into either the "sufficient" or "insufficient" subgroups, depending on the result of the self-reported PA questionnaire. Adverse outcomes, including all-cause mortality, stroke recurrence, and myocardial infarction (MI), were collected from a post-stroke health checkup to 2017.

RESULTS

Of the 34,243 subjects with ischemic stroke, only 21.24% had sufficient PA level after stroke. Among those with insufficient PA level, only 17.34% improved their PA level after stroke. Subjects with sufficient PA level after stroke, regardless of their PA level prior to stroke, showed a lower risk of composite adverse outcomes (adjusted Hazard Ratio [HR], 95% CI: 0.85, 0.80-0.90). Subjects who went from insufficient to sufficient PA level (HR 0.87, 95% CI: 0.81-0.93) showed a significantly lower risk of composite adverse outcomes.

CONCLUSIONS

Achieving a sufficient PA level after ischemic stroke appears to significantly reduce major adverse events. Further effort is needed to promote the PA level after ischemic stroke.

Inclusion of People Poststroke in Cardiac Rehabilitation Programs in Canada: A Missed Opportunity for Referral

BACKGROUND

Evidence supports establishing a continuum of care from stroke rehabilitation (SR) to cardiac rehabilitation programs (CRPs). It is not known to what extent people poststroke are being integrated. This study aimed to determine the proportion of CRPs that accept referrals poststroke, barriers/facilitators, and eligibility criteria.

METHODS

A web-based questionnaire was sent to CRPs across Canada.

RESULTS

Of 160 questionnaires sent, 114 representatives (71%) of 130 CRPs responded. Of respondents, 65% (n = 74) reported accepting people with a diagnosis of stroke and doing so for a median of 11 years, 11 offering stroke-specific classes and an additional 6 planning inclusion. However, 62.5% of CRPs reported that < 11 patients participated in the last calendar year despite 88.5% reporting no limit to the number they could enroll. Among CRPs, 25% accepted only patients with concurrent cardiac diagnoses, living in the community (47.8%), and without severe mobility (70.1%), communication (80.6%), or cognitive (85.1%) deficits. The 2 most influential barriers and facilitators among all CRPs were funding and staffing. The fourth greatest barrier was lack of poststroke referrals, and third to sixth facilitators were SR/CRP collaboration to ensure appropriate referrals (third) and to increase referrals (sixth), toolkits for prescribing resistance (fourth), and aerobic training (fifth). CRP characteristics associated with accepting stroke were a hybrid program model, a medium program size, and having a falls prevention component.

CONCLUSIONS

Most CRPs accept patients poststroke, but few participate. Therefore, establishing SR/CRP partnerships to increase appropriate referrals, using a toolkit to help operationalize exercise components, and allocating funding/resources to CRPs may significantly increase access to secondary prevention strategies.

Increasing time spent engaging in moderate-to-vigorous physical activity by community-dwelling adults following a transient ischemic attack or non-disabling stroke: a systematic review

Purpose: The risk of recurrent stroke following a transient ischaemic attack (TIA) or non-disabling stroke is high. Clinical guidelines recommend this patient population accumulate at least 150 minutes of moderate-to-vigorous physical activity each week to reduce the risk of recurrent stroke. We aimed to identify interventions that increase time adults spend in moderate-to-vigorous physical activity following TIA or non-disabling stroke.Method: We searched thirteen databases for articles of secondary prevention interventions reporting outcomes for duration in moderate-to-vigorous physical activity or exercise capacity.Results: Eight trials were identified (n = 2653). Of these, three (n = 198) reported changes in time spent in moderate-to-vigorous physical activity. Only one trial (n = 70), reported significant change in time spent engaging in moderate-to-vigorous physical activity (between-group difference: 11.7 min/day [95% CI 4.07-19.33]) when comparing participation in a six-month exercise education intervention to usual care. No trial measured moderate-to-vigorous physical activity after intervention end.Conclusion: Despite recommendations to participate in regular physical activity at moderate-to-vigorous intensity for secondary stroke prevention, there is very little evidence for effective interventions for this patient population. There is need for clinically feasible interventions that result in long-term participation in physical activity in line with clinical guidelines. Trial registration: Protocol registration: PROSPERO CRD42018092840Implications for rehabilitationThere is limited evidence of the effectiveness of interventions that aim to increase time spent engaging in moderate-to-vigorous physical activity (MVPA) for people following a TIA or non-disabling stroke.A program comprising aerobic and resistance exercises ≥2 per week, supervised by a health professional (supplemented with a home program) over at least 24 weeks appears to be effective in assisting people adhere to recommended levels of moderate to vigorous physical activity after TIA or non-disabling stroke.Secondary prevention programs which include health professional supervised exercise sessions contribute to better adherence to physical activity guidelines; didactic sessions alone outlining frequency and intensity are unlikely to be sufficient.

Impact of a Stroke Recovery Program Integrating Modified Cardiac Rehabilitation on All-Cause Mortality, Cardiovascular Performance and Functional Performance

OBJECTIVE

Using a feasibility analysis and matched subgroup analysis, this study investigated the implementation/safety/outcomes of a stroke recovery program (SRP) integrating modified cardiac rehabilitation for stroke survivors.

DESIGN

This prospective cohort study of 783 stroke survivors were discharged from an inpatient rehabilitation facility to an outpatient setting; 136 SRP-participants completed a feasibility study and received the SRP including modified cardiac rehabilitation, 473 chose standard of care rehabilitation (nonparticipants), and a group (n = 174) were excluded. The feasibility study assessed the following: safety/mortality/pre-post cardiovascular performance/pre-post function/patient/staff perspective. In addition to the feasibility study, a nonrandomized subgroup analysis compared SRP-participants (n = 76) to matched pairs of nonparticipants (n = 66, with 10 nonparticipants used more than once) for mortality/pre-post function.

RESULTS

The feasibility study showed the SRP to have the following (a) excellent safety, (b) markedly low 1-yr poststroke mortality from hospital admission (1.47%) compared with national rate of 31%, (c) improved cardiovascular performance over 36 sessions (103% increase in metabolic equivalent of tasks times minutes), (d) improved function in Activity Measure of Post-Acute Care domains (P < 0.001), (e) positive reviews from SRP-participants/staff. Subgroup analysis showed the SRP to (a) positively impact mortality, nonparticipants had a 9.09 times higher hazard of mortality (P = 0.039), and (b) improve function in Activity Measure of Post-Acute Care domains (P < 0.001).

CONCLUSIONS

Stroke survivors receiving a SRP integrating modified cardiac rehabilitation may potentially benefit from reductions in all-cause mortality and improvements in cardiovascular performance and function.

Cardiac Rehabilitation: Are People With Stroke or Transient Ischaemic Attack Being Included? A Cross-Sectional Survey

BACKGROUND

Cardiac rehabilitation (CR) may be an effective secondary prevention program for people with stroke or transient ischaemic attack (TIA). The aims of this study were to determine whether people with stroke or TIA were attending CR in Australia and if there were any barriers to attendance.

METHODS

An invitation to participate in an online survey was distributed between January and April 2018, via email, to 411 phase 2 CR coordinators located across Australia. These coordinators were identified through a publicly available directory. The survey contained questions on the demographics of CR programs and attendance of people with stroke or TIA. A Likert scale was used to investigate perceived barriers to CR for people with stroke or TIA. Descriptive statistics were completed for all survey responses except those from open text questions, which were analysed via an inductive qualitative approach.

RESULTS

In total, 149 CR coordinators responded who managed a total of 154 programs. The programs were primarily located in regional (40%) or metropolitan (31%) areas. Nearly 50% of programs were based in a public hospital-based gym/outpatient centre. Over 90% (n = 97/104) of coordinators reported that people with a primary diagnosis of stroke or TIA accounted for less than 2% of their patient population. Despite this, 52% of coordinators thought CR was an appropriate form of secondary prevention for people with stroke or TIA. The largest perceived barriers to attendance were safety (79%, n = 80/101), limited staff to patient ratio (76%, n = 77/101), integration difficulties (68%. n = 69/101) and a lack of referrals (66%, n = 67/101).

CONCLUSION

Few people with a primary diagnosis of stroke or TIA attend CR in Australia, despite over half of CR coordinators believing that CR is appropriate for this group. Cardiac rehabilitation may be particularly suitable for people with mild-stroke or TIA. However, further research is required.

Safety of Performing a Graded Exercise Test Early after Stroke and Transient Ischemic Attack

BACKGROUND

Low cardiorespiratory fitness (CRF) is a predictor of stroke risk and poor outcome poststroke. Fitness levels are rarely assessed in the acute phase and it is unclear if it is safe for stroke survivors and people with transient ischemic attack (TIA) to perform a graded exercise test to assess fitness.

OBJECTIVE

To determine if people within 14 days post stroke can safely perform a graded exercise test.

DESIGN

Observational study.

SETTING

Research institute.

PARTICIPANTS

People with stroke or TIA admitted to an acute stroke unit.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Safety of performing a graded exercise test early post stroke. Safety outcomes were (1) occurrence of an adverse event or (2) <85% blood oxygen saturation (SpO₂ ). Participants performed a graded exercise test on a recumbent stepper at a research institute <2 weeks postevent. CRF was determined by measuring peak volume of oxygen uptake (VO_2peak ) using a metabolic cart.

RESULTS

Twenty-nine participants were enrolled in the study (median age 69 years; interquartile range 58-75). Sixteen were diagnosed with TIA and 13 with a mild stroke. Twenty-eight participants completed the test; one participant was unable to perform the test due to back pain. The test was terminated due to standardized stopping criteria in 26 cases (5 = volitional fatigue, 6 = unable to keep required cadence, 15 = reaching 85% HR_max ), one due to safety (ie, SpO₂  < 85%), and one was inadvertently terminated before stopping criteria were reached. Average CRF determined by the exercise test was low; mean VO_2peak of 16.2 ± 4.5 mL/kg/min for men (n = 20) and 12.4 ± 3.6 mL/kg/min for women (n = 8).

CONCLUSIONS

Determining exercise capacity early post stroke and TIA using a graded exercise test appears to be safe in patients with mild deficits. This information should be useful to plan tailored exercise programs. Further research should focus on determining safety of exercise testing in more severely affected stroke survivors.

Does cardiac rehabilitation for people with stroke in the sub-acute phase of recovery lead to physical behaviour change? Results from compositional analysis of accelerometry-derived data

OBJECTIVES

Does adapted cardiac rehabilitation (CR) improve the physical behaviours of people with mild-to-moderate stroke in the sub-acute recovery phase using a compositional data analysis (CoDA) approach?

DESIGN

Before-after.

SETTING

University Hospitals of Leicester, Glenfield Hospital, UK.

PARTICIPANTS

24 individuals completed CR and provided valid physical activity (PA) data (mean (SD) 63.1 (14.6) years, 58% male (14/24)).

INTERVENTION

6-week adapted CR program within 6-months of stroke.

MAIN OUTCOME MEASURES

Physical behaviours were assessed using waist-worn accelerometry. Step count, stationary time (ST), light PA (LPA), and moderate-to-vigorous PA (MVPA) were compared pre post CR using conventional analyses and CoDA. Analysed compositions were: Waking day (ST, LPA, MVPA); ST (1-9-minutes, 10-29-minutes, ≥30-minutes bouts); and MVPA (1-4-minutes, 5-9-minutes, ≥10-minutes bouts).

RESULTS

Following CR, patients took significantly more steps (mean (SD) 3255 (2864) vs 3908 (3399) steps/day, P=0.004) and engaged in more bouts of MVPA lasting ≥5 and ≥10-minutes (≥5-minutes: mean (SD) 0.7 (1.4) vs 1.2 (1.8) bouts/day, P=0.008). Using CoDA, no changes in waking day or ST compositions occurred. For waking day, 42% (10/24) increased their LPA and MVPA at the expense of ST. For ST, 33% (8/24) increased their short bouts at the expense of medium and long bouts. For MVPA, 13% (3/24) increased their medium and long bouts at the expense of short bouts.

CONCLUSION

People with stroke in the sub-acute stage of recovery exhibited low levels of PA. CR appears to be an effective intervention to increase step count but did not alter the overall proportion of time individuals spent being sedentary, or engaging in LPA or in MVPA.

REGISTRATION

ISRCTN65957980.

Are Aerobic Programs Similar in Design to Cardiac Rehabilitation Beneficial for Survivors of Stroke? A Systematic Review and Meta-Analysis

Background Survivors of stroke face movement disability and increased cardiovascular disease and stroke risk. Treatment includes rehabilitation focused on functional movement with less emphasis on aerobic capacity. After rehabilitation, survivors of stroke must self-manage activity with limited appropriate community programs. Lack of structured activity contributes to sedentary behavior. The objective of this systematic review and meta-analysis is to review aerobic programs for stroke survivors similar in activity and dosage to cardiac rehabilitation programs to determine their efficacy for improving aerobic and walking capacity. Methods and Results Preferred Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to review 5 databases. Group interventions for survivors of stroke with a primary aerobic component and dosage from 18 to 36 visits over 8 to 18 weeks (matching cardiac rehabilitation requirements in the United States) were included. The 6-minute walk test, maximal oxygen consumption (VO2) peak, and walking speed were included as measures of aerobic capacity. Summary effect sizes and outcome measure mean differences were calculated for preintervention to postintervention, and summary effect sizes were calculated for preintervention to follow-up. Activity type and initial 6-minute walk test moderator analyses were performed. Nineteen studies with 23 eligible groups were selected. Survivors of stroke improved their composite aerobic capacity with an effect size of 0.38 (95% CI, 0.27-0.49). Studies including 6-minute walk test demonstrated a pooled difference in means of 53.3 m (95% CI, 36.8-69.8 m). Follow-up data were inconclusive. Conclusions Survivors of stroke benefit from aerobic programs with similar dosing to cardiac rehabilitation in the United States. The potential integration into existing programs could expand the community exercise options.

A systematic review and meta-analysis of the effects of cardiac rehabilitation interventions on cognitive impairment following stroke

PURPOSE

The cardiac rehabilitation model has potential as an approach to providing rehabilitation following stroke. This review aims to identify evidence for the participation of stroke patients in cardiac/cardiovascular rehabilitation programs internationally, whether or not such programs offer a cognitive intervention as part of treatment, and the impact of rehabilitation on post-stroke cognitive function.

METHOD

Five electronic databases were searched from inception to 1 May 2019, namely: MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Central Register of Controlled Trials, and the Web of Science. Eligible studies included both randomized and non-randomized studies of cardiac rehabilitation-type interventions which measured cognitive function in patients with transient ischemic attack (TIA) or stroke.

RESULTS

Of 14,153 records reviewed, nine studies which delivered cardiac rehabilitation-type interventions to stroke patients were finally included. Only three of these studies delivered cognitive rehabilitation as part of the intervention. Cardiac rehabilitation had no statistically significant effect on cognitive function in five randomized controlled trials (standardized mean difference= 0.28, 95% CI= -0.16 to 0.73) or in three one group pre-post studies (standardized mean difference= 0.15, 95% CI= -0.03 to 0.33).

CONCLUSIONS

This review highlights that there are very few studies of delivery of cardiac rehabilitation to stroke patients and that the inclusion of cognitive interventions is even less common, despite the high prevalence of post-stroke cognitive impairment.IMPLICATIONS FOR REHABILITATIONThe cardiac rehabilitation model has the potential to be expanded to include patients post-stroke given the commonality of secondary prevention needs, thereby becoming a cardiovascular rehabilitation model.Up to half of patients experience cognitive impairment after stroke; suggesting that a post-stroke cardiovascular rehabilitation model should incorporate specific cognitive strategies for patients.This systematic review identified three cardiovascular rehabilitation programmes which delivered cognitive rehabilitation as part of treatment; however, evidence for efficacy is weak.

The Impact of Physical Activity Before and After Stroke on Stroke Risk and Recovery: a Narrative Review

PURPOSE OF THE REVIEW

Summarising the evidence for pre- and post-stroke physical activity (PA) and exercise to reduce stroke risk, and improve recovery and brain health.

RECENT FINDINGS

Pre-stroke PA reduces the risk of stroke, and post-stroke PA and exercise reduce cardiovascular risk factors, which can moderate the risk of recurrent strokes. Pre-clinical evidence indicates that exercise enhances neuroplasticity. The results from clinical studies showed that exercise changes brain activity patterns in stroke survivors, which can be a signal neuroplasticity. The intensity of pre- and post-stroke PA and exercise is a key factor with higher intensities leading to greater benefits, including improvement in fitness. Having low fitness levels is an independent predictor for increased risk of stroke. Higher intensity leads to greater benefits; however, the optimum intensity of PA and exercise is yet unknown and needs to be further investigated. Strategies to decrease sedentary behaviour and improve fitness need to be considered.

Comprehensive Cardiac Rehabilitation for Secondary Prevention After Transient Ischemic Attack or Mild Stroke: PSYCHOLOGICAL PROFILE AND OUTCOMES

PURPOSE

Having previously reported that comprehensive cardiac rehabilitation (CCR) is effective for secondary prevention post-transient ischemic attack (TIA)/mild nondisabling stroke (MNDS), we present psychometric findings for the same sample that elucidate subacute TIA/MNDS psychological outcomes and test whether CCR would be independently associated with psychological improvements.

METHODS

In this prospective cohort trial patients with ≥1 risk factor, recruited from a stroke prevention clinic within 12 months (mean = 11.5 weeks) post-TIA/MNDS, entered CCR.

RESULTS

Of the 110 recruited patients, 100 (mean age = 65.4 years; 46 females) entered CCR and 80 completed CCR (mean duration = 7.6 months). At CCR entry, 16.5% and 39.2% screened positively for depression and anxiety, decreasing nonsignificantly at exit to 4.2%, and significantly to 16.9% (P = .008), respectively. Age-corrected deficits occurred more frequently than expected (P ≤ .03); at entry, mental health status (13.3%), clock-drawing (31.6%), oral-verbal fluency (16.9%), word-list learning (11.2%), and recall (12.6%); at exit, clock-drawing (30.0%). Entry-to-exit, mean depression, anxiety, mental and physical health status, word-list learning, memory, digit-symbol coding, and oral-verbal fluency scores improved significantly (P ≤ .031). No reliable change indices were significant. Psychological service recipients improved significantly more than nonrecipients in depression (P = .049). Baseline North American Adult Reading Test score predicted exercise attendance (R = 0.275; P = .044); New York Heart Association (NYHA) class and depression score predicted exit physical health status (R = 0.770, P < .001); and depression score predicted exit mental health status (R = 0.523, P < .001).

CONCLUSIONS

Anxiety and executive dysfunction persisted post-TIA/MNDS. Although promising for secondary prevention post-TIA/MNDS, CCR was not independently associated with psychological improvements. CCR psychological treatment may benefit depression. Subacute NYHA class and depression may later affect quality of life.

Exercise for stroke prevention

We review evidence concerning exercise for stroke prevention. Plausible biological reasons suggest that exercise would be important in preventing stroke. While definitive randomised controlled trials evaluating the impact of physical activity (PA) and exercise on preventing stroke and mortality are lacking, observational studies, small randomised controlled trials and meta-analyses have provided evidence that PA and exercise favourably modify stroke risk factors, including hypertension, dyslipidaemia, diabetes, sedentary lifestyle, obesity, excessive alcohol consumption and tobacco use. It is, therefore, important to understand the factors associated with poststroke PA/exercise and cardiorespiratory fitness. Positively associated factors include self-efficacy, social support and quality of patients' relationships with health professionals. Negatively associated factors include logistical barriers, medical comorbidities, stroke-related deficits, negative exercise beliefs, fear of falling, poststroke fatigue, arthropathy/pain and depression. Definitive research is needed to specify efficacious behavioural approaches to increase poststroke exercise. Effective techniques probably include physician endorsement of exercise programmesto patients, enhancement of patient-professional relationships, providing patients an exercise rationale, motivational interviewing, collaborative goal-setting with patients, addressing logistical concerns, social support in programsmes, structured exercise programming, individualised behavioural instruction, behavioural diary recording, reviewing behavioural consequences of exercise efforts, reinforcing successful exercise performance. Exercise programming without counselling may increase short-term activity; simple advice or information-giving is probably ineffective. Older patients or those with cognitive impairment may need increased structure, with emphasis on behaviour per se, versus self-regulation skills. We support the latest American Heart Association/American Stroke Association guidelines (2014) recommending PA and exercise for stroke prevention, and referral to behaviourally oriented programmes to improve PA and exercise.

Referral of individuals with cardiovascular disease to secondary prevention programmes

BACKGROUND

secondary prevention programmes help manage risk factors, prevent progression of disease, minimise complications and reduce readmissions to hospitals. Referrals to these programmes are suboptimal even though they improve survival and quality of life.

AIM

to explore referral of individuals with a primary diagnosis of acute coronary syndrome, cerebrovascular disease or peripheral vascular disease to secondary prevention programmes.

METHODS

a non-experimental descriptive retrospective design was used to analyse 176 patient records from a tertiary referral hospital in Melbourne, Australia. The study population consisted of individuals over 18 years of age admitted to hospital with a primary diagnosis of acute coronary syndrome, cerebrovascular disease or peripheral vascular disease within a 12-month period in 2009.

FINDINGS

from the patient records reviewed, 34% (n=60) were referred to secondary prevention programmes compared with 66% (n=116) not referred. Individuals with acute coronary syndrome were more likely to be referred than those with peripheral vascular disease or cerebrovascular disease. Those most likely to be referred were young males, married, living in a rural area and English speaking.

DISCUSSION

the study highlights that referrals to secondary prevention programmes are suboptimal. There is a need to investigate reasons for under-referral and the best approach to manage referrals.

CONCLUSION

referrals to secondary prevention programmes are an important area of research: these are beneficial, yet some individuals are not being referred. Nurses are well placed to promote referrals to these programmes potentially. reducing under-referral.

Establishing research priorities relating to the long-term impact of TIA and minor stroke through stakeholder-centred consensus

PLAIN ENGLISH SUMMARY

What is the problem and why is this important? Mini-strokes are similar to full strokes, but symptoms last less than 24 h. Many people (up to 70%) have long-term problems after a mini-stroke, such as anxiety; depression; problems with brain functioning (like memory loss); and fatigue (feeling tired). However, the current healthcare pathway only focuses on preventing another stroke and care for other long-term problems is not routinely given. Without proper treatment, people with long-term problems after a mini-stroke could have worse quality of life and may find it difficult to return to work and their social activities. What is the aim of the research? We wanted to understand the research priorities of patients, health care professionals and key stakeholders relating to the long-term impact of mini-stroke. How did we address the problem? We invited patients, clinicians, researchers and other stakeholders to attend a meeting. At the meeting people discussed the issues relating to the long-term impact of mini-stroke and came to an agreement on their research priorities. There were three stages: (1) people wrote down their individual research suggestions; (2) in smaller groups people came to an agreement on what their top research questions were; and (3) the whole group agreed final research priorities. What did we find? Eleven people attended who were representatives for patients, GPs, stroke consultants, stroke nurses, psychologists, the Stroke Association (charity) and stroke researchers, The group agreed on eleven research questions which they felt were the most important to improve health and well-being for people who have had a mini-stroke.The eleven research questions encompass a range of categories, including: understanding the existing care patients receive (according to diagnosis and geographical location); exploring what optimal care post-TIA/minor stroke should comprise (identifying and treating impairments, information giving and support groups) and how that care should be delivered (clinical setting and follow-up pathway); impact on family members; and education/training for health care professionals.

ABSTRACT

Background Clinical management after transient ischaemic attack (TIA) and minor stroke focuses on stroke prevention. However, evidence demonstrates that many patients experience ongoing residual impairments. Residual impairments post-TIA and minor stroke may affect patients' quality of life and return to work or social activities. Research priorities of patients, health care professionals and key stakeholders relating to the long-term impact of TIA and minor stroke are unknown.Methods Our objective was to establish the top shared research priorities relating to the long-term impact of TIA and minor stroke through stakeholder-centred consensus. A one-day priority setting consensus meeting took place with representatives from different stakeholder groups in October 2016 (Birmingham, UK). Nominal group technique was used to establish research priorities. This involved three stages: (i) gathering research priorities from individual stakeholders; (ii) interim prioritisation in three subgroups; and (iii) final priority setting.Results The priority setting consensus meeting was attended by 11 stakeholders. The individual stakeholders identified 34 different research priorities. During the interim prioritisation exercise, the three subgroups generated 24 unique research priorities which were discussed as a whole group. Following the final consensus discussion, 11 shared research priorities were unanimously agreed.The 11 research questions encompass a range of categories, including: understanding the existing care patients receive (according to diagnosis and geographical location); exploring what optimal care post-TIA/minor stroke should comprise (identifying and treating impairments, information giving and support groups) and how that care should be delivered (clinical setting and follow-up pathway); impact on family members; and education/training for health care professionals.Conclusions Eleven different research priorities were established through stakeholder-centred consensus. These research questions could usefully inform the research agenda and policy decisions for TIA and minor stroke. Inclusion of stakeholders in setting research priorities is important to increase the relevance of research and reduce research waste.

FIT for FUNCTION: study protocol for a randomized controlled trial

BACKGROUND

The current state of evidence suggests that community-based exercise programs are beneficial in improving impairment, function, and health status, and are greatly needed for persons with stroke. However, limitations of these studies include risk of bias, feasibility, and cost issues.

METHODS/DESIGN

This single-blinded, randomized controlled trial (RCT) of 216 participants with stroke will compare the effectiveness of a 12-week YMCA community-based wellness program (FIT for FUNCTION) specifically designed for community-dwelling persons with stroke to persons who receive a standard YMCA membership. The primary outcome will be community reintegration using the Reintegration to Normal Living Index at 12 and 24 weeks. Secondary outcomes include measurement of physical activity level using the Rapid Assessment of Physical Activity and accelerometry; balance using the Berg Balance Scale; lower extremity function using the Short Physical Performance Battery; exercise capacity using the 6-min walk test; grip strength and isometric knee extension strength using hand held dynamometry; and health-related quality of life using the European Quality of Life 5-Dimension Questionnaire. We are also assessing cardiovascular health and lipids; glucose and inflammatory markers will be collected following 12-h fast for total cholesterol, insulin, glucose, and glycated hemoglobin. Self-efficacy for physical activity will be assessed with a single question and self-efficacy for managing chronic disease will be assessed using the Stanford 6-item Scale. The Patient Activation Measure will be used to assess the patient's level of knowledge, skill, and confidence for self-management. Healthcare utilization and costs will be evaluated. Group, time, and group × time interaction effects will be estimated using generalized linear models for continuous variables, including relevant baseline variables as covariates in the analysis that differ appreciably between groups at baseline. Cost data will be treated as non-parametric and analyzed using a Mann-Whitney U test.

DISCUSSION

This is a RCT with broad study eligibility criteria intended to recruit a wide spectrum of individuals living in the community with stroke. If positive benefits are demonstrated, results will provide strong research evidence to support the implementation of structured, community-based exercise and education/self-management programs for a broad range of people living in the community with stroke.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02703805 . Registered on 14 October 2014.

Stroke Prevention Rehabilitation Intervention Trial of Exercise (SPRITE) - a randomised feasibility study

BACKGROUND

The value of cardiac rehabilitation (CR) after a transient ischaemic attack (TIA) or minor stroke is untested despite these conditions sharing similar pathology and risk factors to coronary heart disease. We aimed to evaluate the feasibility of conducting a trial of an adapted home-based CR programme, 'The Healthy Brain Rehabilitation Manual', for patients following a TIA/minor stroke, participants' views on the intervention and, to identify the behaviour change techniques (BCTs) used.

METHODS

Clinicians were asked to identify patients attending the Ulster Hospital, Belfast within 4 weeks of a first TIA or minor stroke. Those who agreed to participate underwent assessments of physical fitness, cardiovascular risk, quality of life and mental health, before random allocation to: Group (1) standard/usual care; (2) rehabilitation manual or (3) manual plus pedometer. All participants received telephone support at 1 and 4 weeks, reassessment at 6 weeks and an invitation to a focus group exploring views regarding the study. Two trained review authors independently assessed the manual to identify the BCTs used.

RESULTS

Twenty-eight patients were invited to participate, with 15 (10 men, 5 women; 9 TIA, 6 minor stroke; mean age 69 years) consenting and completing the study. Mean time to enrolment from the TIA/stroke was 20.5 days. Participants completed all assessment measures except VO2max testing, which all declined. The manual and telephone contact were viewed positively, as credible sources of advice. Pedometers were valued highly, particularly for goal-setting. Overall, 36 individual BCTs were used, the commonest being centred around setting goals and planning as well as social support.

CONCLUSION

Recruitment and retention rates suggest that a trial to evaluate the effectiveness of a novel home-based CR programme, implemented within 4 weeks of a first TIA/minor stroke is feasible. The commonest BCTs used within the manual revolve around goals, planning and social support, in keeping with UK national guidelines. The findings from this feasibility work have been used to further refine the next stage of the intervention's development, a pilot study.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02712385 . This study was registered prospectively on 18/03/2016.

Promoting Physical Activity and Nutrition in People With Stroke

The prevalence of cardiovascular disease, diabetes, and obesity is high in people with stroke. Risk factors for these conditions include hypertension, high cholesterol, and physical inactivity. These risk factors are common in people with stroke and often go unmanaged. Engagement in healthy behaviors is important for managing and preventing these risk factors and comorbid conditions. More specifically, physical activity and nutrition are key health behaviors for the management and maintenance of health in people with stroke. These health behaviors, by their very nature, are also occupations; thus, they are influenced by client factors, performance skills and patterns, and environments and contexts. This article discusses physical activity and nutrition within the context of the Occupational Therapy Practice Framework: Domain and Process and proposes potential roles for occupational therapy practitioners and researchers in developing, testing, and providing physical activity and nutrition interventions for people with stroke.

Post-acute hospital healthcare services for people with mild stroke: a scoping review

BACKGROUND

People with mild stroke comprise a significant proportion of the overall stroke population. Previously this population has been viewed as having limited impairments, receiving minimal services following hospital discharge. Recent findings demonstrate that the implications of mild stroke are more significant than originally comprehended, warranting further services.

OBJECTIVES

To identify the evidence-base regarding services for people with mild stroke, post-acute hospital discharge, that target secondary prevention and/or changes following stroke.

METHODS

Scoping review utilizing the five-stage framework proposed by Arksey and O'Malley, with revisions by Levac, Colquhuon, and O'Brien. Framework stages included: identification of a research question and relevant studies, study selection, charting of data, and collating, summarizing, and reporting. A critical appraisal using the Downs and Black Checklist was added to determine methodological quality of studies. The search strategy used six databases: Pubmed, Embase, PsycINFO, CINAHL, OTseeker, and Scopus, alongside a hand-search. Three researchers were involved in article selection and two in critical appraisal.

RESULTS

Twelve articles met inclusion criteria from 589 identified. A number of study methodologies were used to assess services, with varying methodological qualities. Studies were located within two major regions in the world. Five main approaches to service provision were identified: telehealth, exercise and education, Comprehensive Cardiac Rehabilitation, one-off visits and care-plan development, and community group programs. The majority of programs focused on secondary prevention and were aimed at an impairment level, with a mix of findings observed.

CONCLUSION

Further development and assessment of services is warranted. Incorporation of the entire transition period, and research that is mild stroke and location-specific is advised. Attention to maximizing participation in daily life, secondary prevention, emotional well-being, and careful reporting is needed.

Secondary prevention lifestyle interventions initiated within 90 days after TIA or 'minor' stroke: a systematic review and meta-analysis of rehabilitation programmes

Background

Strokes are often preceded by a transient ischaemic attack (TIA) or ‘minor’ stroke. The immediate period after a TIA/minor stroke is a crucial time to initiate secondary prevention. However, the optimal approach to prevention, including non-pharmacological measures, after TIA is not clear.

Aim

To systematically review evidence about the effectiveness of delivering secondary prevention, with lifestyle interventions, in comprehensive rehabilitation programmes, initiated within 90 days of a TIA/minor stroke. Also, to categorise the specific behaviour change techniques used.

Design and setting

The review identified randomised controlled trials by searching the Cochrane Library, Ovid MEDLINE, Ovid EMBASE, Web of Science, EBSCO CINAHL and Ovid PsycINFO.

Method

Two review authors independently screened titles and abstracts for eligibility (programmes initiated within 90 days of event; outcomes reported for TIA/minor stroke) and extracted relevant data from appraised studies; a meta-analysis was used to synthesise the results.

Results

A total of 31 potentially eligible papers were identified and four studies, comprising 774 patients post-TIA or minor stroke, met the inclusion criteria; two had poor methodological quality. Individual studies reported increased aerobic capacity but meta-analysis found no significant change in resting and peak systolic blood pressure, resting heart rate, aerobic capacity, falls, or mortality. The main behaviour change techniques were goal setting and instructions about how to perform given behaviours.

Conclusion

There is limited evidence of the effectiveness of early post-TIA rehabilitation programmes with preventive lifestyle interventions. Further robust randomised controlled trials of comprehensive rehabilitation programmes that promote secondary prevention and lifestyle modification immediately after a TIA are needed.

A randomized controlled trial to assess the central hemodynamic response to exercise in patients with transient ischaemic attack and minor stroke

Early exercise engagement elicits meaningful changes in peripheral blood pressure in patients diagnosed with transient ischaemic attack (TIA) or minor stroke. However, central hemodynamic markers may provide clinicians with important diagnostic and prognostic information beyond that provided by peripheral blood pressure readings. The purpose of this single-centre, randomized, parallel-group clinical trial was to determine the effect of a 12-week aerobic exercise intervention on central and peripheral hemodynamic variables in patients with TIA or minor stroke. In this study, 47 participants (66±10 years) completed a baseline assessment, which involved the measurement of central and peripheral hemodynamic parameters, undertaken in the morning, in a fasted state. Participants were randomized to either a 12-week exercise or control group on completion of the baseline assessment. An identical follow-up assessment was completed post intervention. Central hemodynamic variables were assessed using an oscillometric device at both assessments. Analysis of covariance demonstrated a significant interaction for central and peripheral blood pressure and augmentation index (all P<0.05; η_p².09–.11), with the exercise group presenting lower values than the control group post intervention (118±17 vs 132±28 mm Hg for central blood pressure; 125±19 vs 138±28 mm Hg for peripheral blood pressure; 104±49 vs 115±67% for augmentation index). The present study demonstrates that participation in an exercise program soon after stroke/TIA diagnosis may elicit significant beneficial changes to a patient's central systolic blood pressure and augmentation index. This may positively impact upon the treatment strategies implemented by clinicians in the care of patients with TIA and minor stroke.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

The long-term effect of exercise on vascular risk factors and aerobic fitness in those with transient ischaemic attack: a randomized controlled trial

OBJECTIVE

Exercise has beneficial effects on vascular risk factors in transient ischaemic attack (TIA) patients within the sub-acute phase. This study examined whether TIA patients randomized to an early exercise and education programme within 2 weeks of TIA diagnosis would demonstrate improvements in cardiovascular risk factors and aerobic fitness 12 months post-diagnosis compared with control patients.

METHODS

A single-centre, randomized, parallel-group clinical trial. Sixty TIA patients (69 ± 11 years) completed a vascular risk stratification baseline assessment and a physical fitness examination. Individuals were randomized to either an 8-week early exercise and education group or control group. Fifty-one patients attended post-intervention assessments that were completed immediately (post-intervention) and 12 months after (12PI).

RESULTS

A significantly greater improvement in resting SBP was observed between baseline and post-intervention for EX than for CON (-11 mmHg cf. -1 mmHg, respectively; P < 0.05). The improvement in SBP was maintained between post-intervention and 12PI (P > 0.05). Similar findings were demonstrated for BMI, bodyweight and peak oxygen uptake (P < 0.05). Exercise blood pressure, pulse pressure and double product (SBP x heart rate; an indication of myocardial workload) were significantly lower at post-intervention and 12PI for EX than for CON (all P < 0.05).

CONCLUSION

An 8-week exercise programme soon after TIA resulted in beneficial changes in resting and exercise blood pressure that were maintained for 12 months.

CLINICAL TRIAL REGISTRATION

http://www.anzctr.org.au/

TRIAL REGISTRATION NUMBER

ACTRN12611000630910.

Does aerobic exercise and the FITT principle fit into stroke recovery?

Sedentary lifestyle after stroke is common which results in poor cardiovascular health. Aerobic exercise has the potential to reduce cardiovascular risk factors and improve functional capacity and quality of life in people after stroke. However, aerobic exercise is a therapeutic intervention that is underutilized by healthcare professionals after stroke. The purpose of this review paper is to provide information on exercise prescription using the FITT principle (frequency, intensity, time, type) for people after stroke and to guide healthcare professionals to incorporate aerobic exercise into the plan of care. This article discusses the current literature outlining the evidence base for incorporating aerobic exercise into stroke rehabilitation. Recently, high-intensity interval training has been used with people following stroke. Information is provided regarding the early but promising results for reaching higher target heart rates.