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The effect of aerobic exercise on stroke rehabilitation

Article  in  Irish Journal of Medical Science · June 2018

DOI: 10.1007/s11845-018-1848-4

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Irish Journal of Medical Science (1971 -)
https://doi.org/10.1007/s11845-018-1848-4

ORIGINAL ARTICLE

The effect of aerobic exercise on stroke rehabilitation

Hande Gezer 1 & Ozgur Zeliha Karaahmet 1 & Eda Gurcay 1 & Deniz Dulgeroglu 1 & Aytul Cakci 1

Received: 17 May 2018 / Accepted: 8 June 2018

# Royal Academy of Medicine in Ireland 2018

Abstract
Background and aims To compare the effects of aerobic exercise and conventional exercise that were applied during the
rehabilitation process on the aerobic capacity, motor function, activity limitation, quality of life, depression level, and sleep
quality in subacute stroke patients.
Methods The patients were divided into two groups; aerobic exercise group (n = 22) or conventional exercise group
(n = 20). Both groups participated in a conventional stroke rehabilitation program; however, aerobic exercise program
was applied only for the patients in group 1. Exercise tolerance test (ETT), respiratory function tests, 6-min walking
test (6-MWT), functional independence measure (FIM), Nottingham health profile (NHP), Beck depression scale
(BDS), and Pittsburgh sleep quality index (PSQI) were evaluated on admission and discharge.
Results The 6-MWT, FIM, some subgroups of NHP, BDS, and PSQI results demonstrated statistical differences in both groups
after rehabilitation programs. Significant differences were recorded in terms of changes between admission and discharge values
of ETT and BDS in favor of aerobic exercise group.
Conclusions Incorporation of aerobic exercises into conventional rehabilitation programs of early stroke patients may provide
positive contributions, particularly to mood and aerobic capacity.

Keywords Aerobic capacity . Exercise . Rehabilitation . Stroke

Introduction This shows a significant functional aerobic impairment,

and that low aerobic capacity causes a decrease in the
Disabilities resulting from stroke cause significant prob- capacity of the stroke patients due to increased energy
lems in physical, psychological, and social aspects of life, need for hemiparetic walking [3, 4], it limits the capacity
and impair quality of life [1, 2]. Because rehabilitation of basic DLA, and contributes to fatigue and intolerance
programs have become critical, investigators focused on to activity [5].
aerobic exercise programs besides classical rehabilitation Aerobic exercise incorporated in the rehabilitation
methods. programs after stroke aims to improve functions after
Metabolic equivalent (MET) calculations of different stroke and prevent recurrent strokes. It is recognized
daily living activities (DLA) revealed that light DLA re- as part of comprehensive stroke rehabilitation in best-
quired an oxygen consumption of approximately 3 MET practice and clinical guidelines, yet many individuals
while heavier ones required approximately 5 MET, or remain physically inactive during hospitalization.
17.5 ml/kg/min oxygen consumption. The peak fitness Although, aerobic exercises have been mostly studied
level of the individuals who had stroke is approximately in patients with chronic stroke, there are relatively few
the half of the level of age-matched sedentary controls. sufficient data for the effects of cardiovascular exercise
programs on the patients with subacute stroke. Therefore,
we aimed to investigate the effect of aerobic exercise in
* Eda Gurcay conjunction with conventional exercise and conventional
[email protected] exercise during rehabilitation process on aerobic capac-
ity, ambulation, activity limitation, quality of life, de-
1
Department of Physical Medicine and Rehabilitation, Dışkapı pression level, and sleep quality of the patients with
Yıldırım Beyazıt Education and Research Hospital, Ankara, Turkey subacute stroke.
 Ir J Med Sci

Methods in 1 s (FEV1), and FEV1/FVC were recorded. ECG, blood

pressure, and heart rate (HR) were followed throughout the
Patients test. The exercise test was stopped when the patient expressed
that he could not continue the test, or if the indications for
A total of 50 patients who were hospitalized in Physical stopping the test appeared. The patients were analyzed with
Therapy and Rehabilitation clinic, and diagnosed with subacute Borg scale for degree of stress where they were given a score
stroke in relation with WHO (World Health Organization) between 0 and 20. ETT duration, max VO2, MET, peak work
criteria were included in the study. Unconscious patients, the load, and peak heart rate were noted.
ones with bilateral or previous hemiplegia, sensory aphasia or
communication problems that could cause problems to com- Exercise program
plete the tests used in the study, comorbid neurological diseases
(multiple sclerosis, Parkinson’s disease, spinal cord injury, trau- Both groups received 1 h/day of conventional rehabilitation
matic brain injury, brain tumor, etc.), and the ones who had any program (with range of motion (ROM), muscle strengthening,
contraindication for maximum exercise test in relation with and mobilization exercises), 5 days a week for 6 weeks.
American College of Sports Medicine were excluded. The pa- Aerobic exercise program was planned for 30 min/day and
tients between the ages of 18–80 years who had a balanced 5 days/week with a value corresponding to 60–80% of the
sitting or could be ambulated were included in the study. The peak heart rate determined according to the ETT with cycling
local ethics committee of the hospital approved the study pro- ergometer. The patients performed warming-up and respira-
tocol. Patients accepted to participate the study were informed tion exercises for 10 min before aerobic exercise. The bicycle
about the study, and their written consents were obtained at the exercise started with a 5-min warming up, and ended with a 5-
beginning of the study. Patients were assigned to either the min cooling period. In warming up phase, the exercise started
aerobic exercise group (group 1) or conventional exercise with a low watt that was increased gradually to the desired
group (group 2). Both groups participated in a conventional watt in 5 min. The watt was decreased gradually in the cooling
stroke rehabilitation program; however, aerobic exercise pro- phase, and the exercise was stopped.
gram was applied only to patients in group 1.
Statistical method
Assessment of the patients
Statistical analyses were performed using SPSS 20.0 for
A questionnaire was used to record age, gender, duration of Windows (SPSS Inc., Chicago, IL, USA). Normality of dis-
stroke, affected side, premorbid exercise habits, and smoking tribution was assessed by Shapiro Wilk test. Descriptive sta-
status of the patients. tistics are given as mean ± standard deviation for continuous
Data collection was carried out at both admission and dis- variables, and as percentage for categorical variables. The
charge. Functional independence state, quality of life, depres- paired t test or Wilcoxon test was used to reveal whether there
sion level, and sleep quality were evaluated with Functional was a significant difference within the groups. The Fisher
Independence Measurement (FIM) [6, 7], Nottingham Health exact test was used to assess the qualitative differences be-
Profile (NHP) [8], Beck depression scale (BDS) [9], and tween the groups. Numerical variables were compared using
Pittsburgh sleep quality index (PSQI) [10, 11], respectively. the Student t test or Mann–Whitney U test as appropriate.
The patients walked in a 30-m corridor at the walking Statistical significance was set at p < 0.05.
speed they preferred, and the distance they walked in 6 min
was recorded by 6-min walking test (6-MWT).
Respiratory function test and then exercise tolerance test Results
(ETT) on bicycle ergometry were performed to analyze exer-
cise capacities of the patients. The patients did not eat any- A total of 50 patients were enrolled in this study. There were
thing for at least 3 h prior to the test, and they did not smoke or 27 patients in aerobic exercise group and 23 patients in con-
consume caffeine. Before the test, 12-derivation electrocardi- ventional exercise group. Five patients in group 1 and 3 pa-
ography (ECG) and blood pressure were recorded. Bicycle tients in group 2 could not complete the physical exercise
ergometry was performed with Care Fusion Type Master program due to their comorbid diseases. Demographic and
Screen-CPX device. In the first 3 min, 50 rpm without load clinical data of the patients are presented in Table 1.
was employed, then the load was increased by 5 W every A total of 6 patients were exercising regularly prior to
minute. The patients used a mask with a gas-meter to measure stroke and 13 patients were smoking in both groups. Groups
oxygen inspiration and carbon dioxide exhalation during the were similar for the rates of regular exercise and smoking.
test. After spirometric analysis, oxygen uptake volume (VO2 Comparison of admission and discharge values of the
ml/kg/min), forced vital capacity (FVC), forced vital capacity groups for ETT, respiratory function test, 6-MWT, FIM,
Ir J Med Sci

Table 1 Clinical and

demographic characteristics of the Group 1 (n = 22) Group 2 (n = 20) p
patients
Age (year), mean ± (SD) 52.6 ± 2.9 56.3 ± 3.3 0.420
Duration of stroke (day), mean ± SD 56.5 ± 10.3 65.9 ± 8.3 0.490
Gender n (%) Female 7 (%31.8) 8 (%40) 0.585
Male 15 (% 68.2) 12 (%60)
Affected side n (%) Right 11 (%50) 6 (%30) 0.193
Left 11 (%50) 14 (%70)
Brunnstrom stage (upper) 5 (1/6) 4.5 (1/6) 0.886
median (min–max)
Brunnstrom stage (lower) 5 (1/6) 5 (1/6) 0.556
median (min–max)

SD, standard deviation

BDS, and PSQI results are revealed in Tables 2, 3, 4, 5. When exercise programs are essential in this group of patients [12].
intergroup analyses of the abovementioned tests were done, it Significant differences were recorded in terms of changes be-
was noted that only the BDS showed significant differences in tween admission and discharge values of ETT and BDS in
admission and discharge changes (p = 0.038). favor of aerobic exercise group in this study.
Subgroups of NHP including energy, emotional reactions, Max VO2 represents the maximum oxygen amount used
sleep, and physical activity scores in aerobic exercise group, during maximum dynamic exercise, and it is the best indicator
pain, sleep, and physical activity scores in conventional exer- of aerobic capacity. A significant decrease starts in the early
cise group revealed significant differences (p < 0.05). No dif- period in stroke patients, and this decrease continues if neces-
ference was noted for changes of admission and discharge sary programs are not employed. Studies reported that max
NHP values between groups. VO2 decreased to 10–17 ml/kg/min 0–30 days after stroke
[13]. In accordance with the literature, our data showed that
max VO2 capacity of the patients was 10.7 ml/kg/min after a
Discussion mean period of 61 days after stroke. In our aerobic exercise
group, the mean admission max VO2 was 10.0 ml/kg/min
Stroke takes the first place for frequency and importance while this value increased to 12.6 ml/kg/min after rehabilita-
among the neurological disorders of adulthood. It has been tion program, and the difference between two values was sta-
reported that the mean aerobic capacity of the stroke patients tistically significant. Aerobic exercise in conjunction with
decreases by 60% in the first month after stroke compared to conventional exercise demonstrated superior improvement
age- and sex-matched healthy controls. Therefore, aerobic than conventional exercise.

Table 2 Comparison of
admission and discharge values of Admission Discharge p
ETT results mean ± SD mean ± SD

Group 1 ETT duration (min) 6.3 ± 3.59 8.8 ± 4.02 0.07

Max VO2 (l/min) 10.0 ± 2.69 12.6 ± 3.25 < 0.001
MET (kcal/kg) 2.8 ± 0.76 3.6 ± 0.92 < 0001
Peak work load (watt) 18.9 ± 14.27 38.0 ± 21.28 < 0.001
Borg scale 16 ± 1.19 14.3 ± 1.56 < 0.001
Peak heart rate (beats/min) 109.9 ± 18.01 118.2 ± 21.51 0.042
Group 2 ETT duration (min) 5.8 ± 3.34 5.5 ± 3.06 0.513
Max VO2 (l/min) 11.4 ± 4.29 10.5 ± 3.24 0.241
MET (kcal/kg) 3.2 ± 1.22 2.9 ± 0.92 0.244
Peak work load (watt) 23.4 ± 22.30 18 ± 13.86 0.177
Borg scale 15.7 ± 1.83 15.5 ± 1.98 0.465
Peak heart rate (beats/min) 113.8 ± 21.50 114.2 ± 21.72 0.925

A value of p < 0.05 was considered to be statistically significant

ETT, exercise tolerance test; MET, metabolic equivalent; SD, standard deviation
 Ir J Med Sci

Table 3 Comparison of admission and discharge values of respiratory Table 5 Comparisons of admission and discharge values of BDS and
function test results PSQI results

Admission Discharge p Admission Discharge p

mean ± SD mean ± SD mean ± SD mean ± SD

Group 1 FEV1 (l) 2.29 ± 1.12 2.4 ± 0.97 0.480 Group 1 BDS 13.9 ± 8.28 7.64 ± 7.07 < 0.01
FVC (l) 2.94 ± 1.26 3.2 ± 1.14 0.033 PSQI 5.6 ± 4.63 3.55 ± 3.09 0.034
FEV1/FVC (%) 77.1 ± 9.38 78.2 ± 9.41 0.516 Group 2 BDS 14.5 ± 7.13 12.20 ± 9.31 0.04
Group 2 FEV1 (l) 2.0 ± 0.67 2.1 ± 0.81 0.962 PSQI 9.1 ± 5.74 5.75 ± 5.05 0.002
FVC (l) 2.5 ± 0.82 2.5 ± 1.12 0.835
A value of p < 0.05 was considered to be statistically significant
FEV1/FVC (%) 81.6 ± 11.22 84.8 ± 8.46 0.962
BDS, Beck depression scale; PSQI, Pittsburgh sleep quality index; SD,
A value of p < 0.05 was considered to be statistically significant standard deviation
FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity
An important issue in aerobic exercise programs is the pul-
monary capacity of the patient. Lennon et al. studied efficiency of
Billinger et al. examined the patients with subacute stroke a 10-week aerobic exercise program, and did not find any signif-
with ETT. The mean pre-treatment test duration was 654 s icant differences in intragroup and intergroup analyses of exer-
while this value increased to 700 s after treatment, however cise and control groups [16]. Similar to the literature, we only
the difference was not statistically significant [14]. In our found a significant increase in FVC in aerobic exercise group;
study, ETT time was 6.39 min before treatment, and increased however, there were no differences for FEV1 and FEV1/FVC.
to 8.89 min after treatment in aerobic exercise group. In con- Recent studies analyzed smoking and physical activity in
ventional exercise group, pretreatment ETT time was stroke patients, and reported rates of 30% for smoking [15]
5.87 min and posttreatment ETT time was 5.56 min. The and 40% for regular exercise before stroke [14]. In our study,
changes in ETT time were not significant in either group; 18% of the patients were exercising regularly in aerobic exer-
however, comparison of two groups revealed that ETT time cise group, and 31.8% of them were smoking. Those rates were
was significantly longer in aerobic exercise group when com- 10 and 30%, respectively, in the conventional exercise group.
pared to conventional exercise group. Katz-Leurer et al. studied 92 patients with subacute stroke,
For an efficient aerobic exercise, the exercise must be per- and did not find any significant difference for pre- and post-
formed at the 60–80% of the peak heart rate calculated accord- treatment total FIM scale scores of aerobic exercise group, and
ing to the age of the patient. However, most of the stroke the control group [17]. Although we found significant increase
patients end the test before they reach target heart rate. Tang in admission and discharge FIM motor and total scores in both
et al. found 5% difference in peak heart rate between pre- and groups, intergroup analysis did not reach a significant result.
post-treatment periods in the exercise group while this differ- Depression revealed a statistically significant improvement
ence was 11% in the control group; however, the change in the after rehabilitation process in both aerobic and conventional
heart rate was not found significant [15]. In our study, although exercise scores. Comparison of two groups showed better im-
no significant difference was obtained in the conventional ex- provement in aerobic exercise group than the conventional
ercise, significant results were noted for peak heart rate in exercise group. Similarly, Smith et al. reported that a 4-week
aerobic exercise group after rehabilitation program. aerobic exercise program applied to patients with chronic

Table 4 Comparisons of
admission and discharge values of Admission Discharge p
6-MWT and FIM score results mean ± SD mean ± SD

Group 1 6-MWT 173.6 ± 81.84 239.4 ± 120.15 <0.001

FIM motor 66.9 ± 17.94 77.7 ± 14.77 <0.01
FIM cognitive 32.5 ± 5.40 32.7 ± 5.28 0.131
FIM total 99.8 ± 17.62 110.5 ± 14.71 <0.01
Group 2 6-MWT 172.7 ± 107.03 222.3 ± 99.76 0.044
FIM motor 64.4 ± 18.90 77.2 ± 15.71 <0.01
FIM cognitive 31.9 ± 4.62 33.1 ± 3.44 0.018
FIM total 96.3 ± 21.39 110.2 ± 17.75 <0.01

A value of p < 0.05 was considered to be statistically significant

6-MWT, 6-min walking test; FIM, Functional Independence Measurement, SD, standard deviation
Ir J Med Sci

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