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California State University, Northridge
Post-Stroke Physical Activity: Reference Guide for Non-Clinicians
A project submitted in partial fulfillment of the requirements
For the degree of Master of Science in
Kinesiology
By
Cynthia Valencia
August 2012
ii
The project of Cynthia G. Valencia is approved:
Sharon Hsu, Ph.D. Date
S. Victoria Jaque, Ph.D. Date
Konstantinos Vrongistinos, Ph.D., Chair Date
California State University, Northridge
iii
TABLE OF CONTENTS
Signature Page ii
Abstract iv
Introduction 1
Literature Review 4
Hemiparetic Gait Characteristics 4
Barriers 4
Post-Stroke Fall Risk 5
Psychosocial Impact 6
Treadmill Intervention 6
Energy and Gait Speed 7
Body-Weight Supported Treadmill Intervention 8
Functional Electrical Stimulation 9
Balance Intervention 10
Aquatic Intervention 10
Assistive Devices 11
Gait Velocity and Other Variables 12
Community and Home-Based Programs 13
Post-Stroke Physical Activity Manual 15
Stroke 15
Stroke Lower Extremity Characteristics 15
Professional Rehabilitation and Training Programs 17
Physical Activity Barriers 19
Evidence-Based Physical Activity for Stroke Survivors 20
How the Manual will be Utilized 27
Future Needs for a Manual and Updates 28
References 29
iv
ABSTRACT
Post-stroke Physical Activity: Reference Guide for Non-Clinicians
By
Cynthia G Valencia
Master of Science in Kinesiology
This Post-Stroke Physical Activity Reference Guide for Non-Clinicians was
developed to provide a reference guide for non-clinicians such as adapted physical
activity students and caregivers, family responsible for care of the post-stroke individual,
and the post-stoke individual. Topics include etiology, prevalence and cost, significance
of gait restoration, common symptoms with a focus in the lower extremities, and review
of intervention programs for post-stroke rehabilitation, and evidence-based physical
activity exercises for the post-stroke individual. The purpose of this project was to create
a reference guide designed to provide insight into the etiology, prevalence, rehabilitation
program designs implemented by physical therapists, and provide physical activity
examples to implement with the post-stroke individual. The contents will enable non-
clinicians to aid the post-stroke individual in completing physical activity.
1
Introduction
In the United States, 750,000 strokes occur annually (Patterson, Rodgers, Macko,
& Forrester, 2008). Stroke is considered to be the leading cause of chronic disability
(Eng, Pang, & Ashe, 2008) with incidence doubling relatively each decade after the age
of 55 (Pang, Eng, Dawson, McKay, & Harris, 2005). Estimated costs of ischemic stroke
from 2005 to 2050 are believed to exceed $2.2 trillion (Stuart, Chard, & Roettger, 2008).
The literature supports the need for new creative methods that will improve the health of
individuals post-stroke through physical activity and reduce costs associated with chronic
stroke health issues (Stuart et al., 2008). Studies have suggested community exercise
programs as a method to provide physical activity options in hopes of improving health in
the stroke individual and reducing costs associated with deconditioning in this population
(Lindahl, Hansen, Pedersen, Truelsen, & Boysen, 2008; Macko et al., 2008). Stroke
survivors can gain health benefits from physical activity; however, physical fitness
programs for this population are not readily available (Lindahl et al., 2008).
Socioeconomic status may also serve as a barrier between the stroke survivor and
physical activity programs. Studies have reported community group exercise programs
as a cost-effective solution to offer physical activity to the stroke population (Macko et
al., 2008).
Strokes generally fall into two categories, ischemic and hemorrhagic. There are
many risk factors for stroke. These factors include high blood pressure, diabetes,
atherosclerosis, tobacco use, alcohol use, high cholesterol, obesity, and sedentary lifestyle
(Hayes, 2012). Improvements in ambulatory function and fitness in the post-stoke
individual may continue to improve many years after a stroke (Macko et al., 2008).
2
Restoration of gait, the pattern of how an individual walks, has high priority in
post-stroke rehabilitation (Peurala, Airaksinen, Jäkälä, Tarkka, & Sivenius, 2007). The
importance of walking function is important in the performance of activities of daily
living, independence, and reduction of secondary health issues (Patterson et al., 2008).
Secondary health issues may include reduced cardiovascular function, obesity,
osteoporosis, and decreased flexibility. Sixty to 70% of individuals who suffer a stroke
recover the ability to walk by the time they are discharged from the hospital; however, 7-
22% of these individuals are restricted to ambulation within their homes (Brouwer,
Parvataneni, & Olney, 2009). The increased incidences of stroke and higher survival
rates after a stroke have resulted in a need for post-stroke physical activity programs
(Pang et al., 2005). These factors highlight the importance of finding ways to implement
physical activity in community or home-based programs for the post-stroke population
(Lindahl et al., 2008; Macko et al., 2008). Creation of these programs can potentially
improve health in stroke survivors and reduce costs associated with chronic stroke (Stuart
et al., 2008). A manual containing background information on stroke, such as
rehabilitation/training programs and evidence-based physical activity suggestions for the
stroke survivor would be useful for the post-stroke individual, individuals caring for the
stroke survivor, and non-clinicians, such as adapted physical activity students.
The purpose of this project was to create a reference guide designed to provide
insight into the etiology, prevalence, rehabilitation program designs implemented by
physical therapists, and physical activity ideas to implement with the post-stroke
individual. The contents will enable non-clinicians to aid the post-stroke individual
complete physical activity under supervision.
3
Literature Review
Hemiparetic Gait Characteristics
The impact of stroke on the post-stroke patient’s ambulation can extend from
acute and sub-acute phases to chronic post-stroke phase. Motor impairments experienced
by post-stroke patients include spasticity, weakness, proprioceptive deficits, and impaired
selective motor control (Sullivan, Mulroy, & Kautz, 2009). Hemiparetic gait often results
in the post-stroke patient, which is characterized by weakness on one side of the body
(Sullivan et al., 2009; Yavuzer, Eser, Karakus, Karaoglan, & Stam, 2006). For example,
post-stroke hemiparetic patients exhibit foot drop during swing phase in the paretic leg,
lack of initial contact or heel strike, knee instability in the sagittal plane, and medio-
lateral ankle instability during stance phase (Yavuzer et al., 2006). Exaggerated postural
sway in the sagittal and frontal planes is also evident (Yavuzer et al., 2006). Pelvic
hiking is also seen in this population during the swing phase in the paretic limb as a result
of the lack of knee flexion (Chen & Patten, 2006). Sullivan et al. (2009) noted that
compensations of increased activity in the paretic hip flexor are in response to weak
plantar flexors; this is accomplished to increase walking speed. One study by showed
that knee flexors in the hemiparetic limb have a role in predicting gait speed (Nasciutti-
Prudente et al., 2009), which is a measure of gait performance in post-stroke participants
(Rao et al., 2008). The degree of power output of the hemiparetic limb has also been
shown to have a relationship with gait speed (McGinley, Goldie, Greenwood, & Olney,
2003). Disruption of motor neuron pathways and disuse contribute to the paresis and
further deconditioning (Sullivan et al., 2009). Rehabilitative action is needed to improve
the individual’s physical well-being. Lack of rehabilitation in this population can lead to
4
further reduction in strength and range of motion, and can result in contractures (Sullivan
et al., 2009). Peurala et al. (2007) suggest that gait intervention programs should begin
early because major improvements are made during the first month post-stroke and may
not be attained in later stages of gait rehabilitation.
Another characteristic of hemiparetic gait is a longer stance phase on the non-
paretic leg, which results in a shorter stance phase on the paretic leg (Bensoussan Mesure,
Viton, & Delarque, 2006; Brouwer et al., 2009; Chen & Patten, 2006). The stance to
swing phase ratio for each of the legs shows the degree of symmetry in the individual’s
gait pattern (Hesse, 2003). Step length asymmetry, and single support time asymmetry
ratios between the paretic and non-paretic leg, respectively, are also indicative of the
degree of symmetry; a greater ratio indicates a greater degree of asymmetry (Yavuzer et
al., 2006). A longer stance phase produces asymmetrical gait with greater body-weight
distribution experienced by the non-paretic leg (Bensoussan et al., 2006). Reduced
walking speed, cadence (Hesse, 2003), and longer double support phase and gait cycle is
also exhibited in this population when compared with healthy individuals (Nasciutti-
Prudente, 2009). The literature indicates that post-stroke walking rehabilitation programs
that include task-specific training, lower-extremity strengthening, and aerobic training are
more effective than conventional neurophysiologic approaches implemented by physical
therapists (Sullivan et al., 2009).
Barriers
Low levels of physical activity participation have been reported in the stroke
population (Pang et al., 2005; Rimmer, Wang, & Smith, 2008). Barriers associated with
5
the low levels of engagement in physical activity include personal, environmental, and
financial barriers (Rimmer et al., 2008).
Lack of independence plays a role as a barrier to access to physical activity opportunities.
Driving was reported as an important determinant in becoming independent again. Post
stroke individuals who did not drive needed to rely on availability of family members,
friends, or use private or public transportation to access physical activity centers such as
private gymnasiums or community centers for leisure activities (O'Sullivan & Chard,
2010). Functional impairments also prevent this population from engaging in physical
activity. Post-stroke individuals note poor mobility, poor standing tolerance, fatigue, and
loss of leg and hand function as their inability to return to active leisure (O’Sullivan &
Chard, 2010). Factors affecting physical activity in stroke survivors include
socioeconomic factors, lack of support, and lack of motivation (Rimmer et al., 2008).
Post-Stroke Fall Risk
Post-stroke individuals have a higher incidence of falls. One study reports a high
percentage, 70%, in the post-stroke population within the first six months after stroke
(Dean et al., 2012). Asymmetric gait in the post-stroke population results in a higher
energy expenditure when compared to individuals without gait dysfunction.
Furthermore, the asymmetric gait also increases the fall risk in this population (Yavuzer
et al., 2006). The risk of falls is highly related to the asymmetric body-weight
distribution exhibited by the post-stroke individual (Noh et al., 2008).
Approaches that incorporate fall prevention are important in the rehabilitation of a
post-stroke individual (Weerdesteyn, de Niet, van Duijnhoven, & Geurts, 2008). A post-
stroke individual is more likely to engage in community activities such as church, grocery
6
shopping, family and other social engagements when they have higher walking function
(Sullivan et al., 2009). The abnormal walking mechanics exhibited by this population
increases the fall risk and injury as a result of falls (Weerdesteyn et al., 2008). Assistive
devices offer stability and decrease an individual’s fall risk (Rao et al., 2008). Exercises
such as repetitive sit-to-stand exercises have been shown to reduce the risk of falls in the
post-stroke population (Noh et al., 2008). Eight to 69 percent of post-stroke individuals
will experience a fall with mild injuries, such as scrapes or bruises. Furthermore,
individuals who experienced at least 2 falling experiences had a fracture incidence of 0.6
to 8.5 percent (Weerdesteyn et al., 2008).
Psychosocial Impact
The resulting injuries of these falls have a physical and psychosocial impact.
After a fall, the individual may be less apt to participate in social engagements because of
their fear of falling; as a result, becoming less physically active and further deconditioned
(Weerdesteyn et al., 2008). In contrast, a study examining secondary benefits to
treadmill training with twenty post-stroke participants in the experimental group matched
with same-side hemiparetic post-stroke participants in a control group yielded
improvements in depression, social participation, and mobility; however, the
improvements in the experimental group were not statistically significant when compared
to the controls (Smith & Thompson, 2008).
Treadmill Intervention
The severity of the individual’s stroke has a strong relationship with the degree of
regaining normal walking mechanics and the rate at which improvements in mobility are
made (Hesse, 2003; Sullivan et al., 2009). The effectiveness of a rehabilitation program
7
is dependent on the type of exercise program, stroke severity, and length of time from the
onset of stroke (Noh et al., 2008). Functional improvements are attained quicker in
individuals that experienced mild to moderate strokes are and to a greater degree
compared to those who experienced a severe stroke (Sullivan et al., 2009). Different
approaches have been utilized by practitioners to help restore gait function in individuals
post-stroke.
For example, treadmill training has gained increased recognition as a training
intervention to restore gait function (Brower et al., 2009; Chen, & Patten, 2006). Task-
specific gait training can be achieved using a treadmill to make improvements in gait
speed and endurance (Sullivan et al., 2009). Furthermore, the literature suggests
improvement in overground walking after treadmill training interventions in older
participants with hemiparetic gait (Lindquist et al., 2007). Brouwer et al. (2009) found
similar kinematic profiles for overground walking and body-weight supported treadmill
walking in the post-stroke participants observed. Treadmill walking produced greater
inter-limb symmetry when compared to overground walking (Brouwer et al., 2009; Chen
& Patten, 2006). Total excursion maximum and minimum angles for the hip, knee, and
ankle have been found to be similar in overground and matched treadmill walking speeds
in post-stroke participants (Brouwer et al., 2009).
Energy and Gait Speed
Treadmill walking incurs higher metabolic energy cost compared to overground
walking (Brouwer et al., 2009). For example, higher heart rates and oxygen consumption
were evident with treadmill walking versus overground walking (Brower et al., 2009).
Smith & Thompson (2008) suggest the use of a treadmill to enhance a post-stroke
8
individual’s gait speed. Although improvements in symmetry may not be evident with
minor increases in treadmill speeds, the literature suggests moderate increases to
treadmill speed to challenge to improve walking efficiency by activating weight bearing
muscles on the paretic leg (Chen & Patten, 2006). Changes in gait speed have been
attained in as little as 12 training sessions and seen up to 3 months after treadmill
intervention (Smith & Thompson, 2008). Furthermore, training interventions that
incorporate treadmill training at higher intensities have shown to be more advantageous
to improve gait speed (Sullivan et al., 2009). Brouwer et al. (2009) reported greater gait
symmetry with treadmill walking compared to overground walking because the
participant had to make compensations in their gait to match the constant treadmill speed.
A disadvantage with treadmill training is that it can require up to two to three people to
control the hemiparetic individual’s trunk movement and placement guiding of the
paretic limbs (Chen & Patten, 2006; Hesse, 2003).
Body-Weight Supported Treadmill Intervention
Body-weight supported treadmill walking has also been used as a gait training
intervention. In body-weight supported treadmill walking, the hemiparetic participant is
placed in a harness which supports a portion of their body-weight (Hesse, 2003). As a
result, the participant improves walking posture to a more upright position (Chen &
Patten, 2006) and reduces the degree of collapse and excessive hip flexion exhibited by
the paretic leg during the single stance phase (Hesse, 2003). Increased symmetry has
been shown in hemiparetic patients during body-weight support treadmill walking with
an optimum body-weight support by the harness between 15 and 30 percent (Chen &
Patten, 2006; Hesse, 2003). A study by Lindquist et al. (2007) found improvements in
9
temporal and spatial variables in hemiparetic gait after a 9 week body-weight supported
treadmill intervention. Furthermore, Sullivan et al. (2009) has reported that better gait
outcomes are achieved with the use of body-weight support in treadmill interventions
compared to treadmill interventions without body-weight support. Chen & Patten (2006)
note variability in treadmill body-weight supported interventions exist; they indicate that
the protocol varies from study to study such that one study may allow the use of a
handrail and one may offer the participant manual assistance with limb placement or
trunk control. This should be taken into account when analyzing studies that utilize
body-weight support treadmill interventions.
Functional Electrical Stimulation
Electromyographic (EMG) data has shown increased muscle activation in the paretic
limb when using treadmill walking versus an overground walking situation (Brouwer et
al., 2009). A study by Lindquist et al. (2007) used functional electrical stimulation (FES)
using intramuscular electrodes to stimulate lower limb muscles combined with body-
weight supported treadmill walking. The site of applied FES was to the peroneal nerve.
Hesse (2003) reports electrical stimulation as beneficial tool in gait rehabilitation post-
stroke. The study by Lindquist et al. (2007) found that FES combined with a body-
weight supported treadmill intervention may promote more improvements in spatial and
temporal variables than an isolated body-weight support treadmill intervention at 9
weeks. Although a useful intervention, Hesse (2003) suggests that electrical stimulation
should not be used daily.
10
Balance Intervention
Balance training has also been used and provides improvements in postural
control and weight bearing on the paretic side during walking (Yavuzer et al., 2006).
Balance training programs aim to improve the individual’s posture and weight bearing on
the paretic limb (Yavuzer et al., 2006). The hip adductor and abductor muscles play a
key role in balance control (Yavuzer et al., 2006). EMG studies have reported decreased
activity in the hip adductor and abductor muscles in hemiparetic patients (Bensoussan et
al., 2006). The use of walking aids such as canes can further reduce the muscle activity
exhibited by the hip adductors because of the decreased force production as a result of a
longer lever arm of the gluteus medius, yielding the same torque output (Hesse, 2003).
Yavuzer et al. (2006) found that targeting the hip adductor and abductor muscles are
important factors to reduce gait asymmetry, improve balance, and reduce the individual’s
fall risk. Hesse (2003) suggests that balance training should be implemented as task-
specific balance training, because standing balance training does not yield improvements
in gait symmetry in hemiparetic individuals. Conversely, Sullivan et al. (2009) reports a
strong correlation between walking speed and standing balance post-stroke; especially in
individuals with more severe impairments.
Aquatic Intervention
Aquatic therapy has been shown to yield improvements and balance with
improved weight bearing and degree of knee flexion (Noh, Lim, Shin, & Paik, 2008).
Aquatic therapy offers post-stroke patients the opportunity to move with less effort and to
move in different movement planes independently (Noh et al., 2008). Aquatic therapy
using Ai Chi and Halliwick methods has been shown to improve postural balance and
11
knee flexor strength of the hemiparetic limb in post-stroke individuals in an eight week
aquatic intervention program (Noh et al., 2008). Improved postural balance and knee
flexor strength have been shown to positively affect gait outcome (Nasciutti-Prudente et
al., 2009). Postural control has been shown to affect weight bearing on the paretic leg,
which has a positive effect on gait (Yavuzer et al., 2006). In a study by Noh et al. (2008)
significant changes in knee flexor strength were evident in the aquatic therapy group
compared to a conventional therapy group; the changes in knee flexion resulted from the
repetitive flexion and extension movements during therapy. Peurala et al. (2007)
advocates that post-stroke gait training be task-specific and intensive. The use of aquatic
therapy enables the post-stroke individual to have repeated and intensive training that the
individual may perform individually, where it would not be possible to work individually
using land-based techniques (Noh et al., 2008).
Assistive Devices
In addition to training interventions, practitioners may utilize an orthotic device
such as an ankle foot orthosis (AFO), which helps promote sagittal knee stability and
reduce ankle foot drop by restricting the movement at the ankle joint (Hesse, 2003; Rao
et al., 2008; Sullivan et al., 2009). Furthermore, the use of an AFO has been shown to
increase gait velocity in individuals who suffered an acute or chronic stroke (Rao et al.,
2008). For optimal results the AFO should be fitted to the individual; the AFO has been
shown to improve step length, stride length, and cadence for this population (Rao et al.,
2008). When the use of an AFO is insufficient and the individual has impaired
proprioception that extends to the paretic knee a knee-ankle-foot orthosis (KAFO) may
be prescribed (Sullivan et al., 2009). Other assistive devices such as quad canes or short
12
canes are also prescribed to the hemiparetic patient to promote stability (Hesse, 2003).
The use of assistive devices may offer the post-stroke patient greater confidence in
walking because of the support offered. The use of canes by post-stroke hemiparetic
individuals has been shown to provide about 15 percent of body-weight support (Hesse,
2003).
Gait Velocity and Other Variables
Common gait outcome variables examined are ground reaction forces at toe-off
during gait, gait velocity, step length, stance to swing phase ratio, cadence, and range of
motion at the knee and ankle (Sullivan et al., 2009). Instrumentation such as force plates,
motion analysis, and observation have been used to assess gait outcome variables. The
use of motion analysis (Rao et al., 2008) and ground reaction force (GRF) plates have
proven to be reliable and valid measures in the analysis of gait in post-stroke patients
(Brouwer et al., 2009; Yavuzer et al., 2006). Gait velocity is an important variable that
has been shown to influence roughly 80 percent of all other gait variables (Hesse, 2003).
Gait velocity has been associated with the post-stroke individual’s balance, muscular
strength, and walking independence (Nasciutti-Prudente et al., 2009). It is also used as a
primary measure of recovery in post-stroke individuals (Rao et al., 2008; Sullivan et al.,
2009). Combined, cadence and stride length are determinants of gait velocity (Sullivan et
al., 2009). Vertical GRF patterns are evident in hemiparetic walking; Sullivan et al.
(2009) reports reduced vertical GRF forces in the paretic leg during walking. An
alternative to using expensive instrumentation is observational gait analysis, which is
commonly used by physical therapists and proven as a reliable method of assessment in
post-stroke individuals (McGinley et al., 2003).
13
Community and Home-Based Programs
Community or other innovative programs, such as home-based programs
(Rimmer et al., 2008) have the potential to improve health in stroke survivors and help
reduce health care costs through prevention of secondary health issues associated with
decreased physical activity in this population (Stuart et al., 2008). Community based
physical activity programs targeting stroke survivors could offer a solution to the
survivor’s complaint of a personal trainer, or exercise fitness instructor at a fitness facility
would not be able to know how to help a post-stroke individual (Rimmer et al., 2008).
The Fitness and Mobility Exercise (FAME) program implemented by Pang et al.
(2005) involved three one hour sessions per week over the course of nineteen weeks in
the form of a group exercise model. The group exercise program was supervised by a
physical therapist, occupational therapist, and exercise instructor with twelve participants
per group. The FAME program has been proven to be an evidence-based intervention
focused on the stroke population that can be implemented in community and home
settings. This intervention program utilized family supervision and involvement in
physical activity exercises to optimize stroke survivor’s recovery. The program trained
the family members to carry out the exercise program, which resulted in a significant
increase in the additional amount of physical activity obtained outside of professional
rehabilitation. The increased level of physical fitness of the stroke survivors resulted in
decreased levels of caregiver strain when compared to the control group (Galvin, Cusack,
O’Grady, Murphy, & Strokes, 2011).
Restoration of gait is an important and primary goal in post-stroke rehabilitation
(Peurala et al., 2007). Walking function plays a key role in the performance of activities
14
of daily living, independence, and reduction of secondary health issues (Patterson et al.,
2008). Treadmill training, body-weight supported treadmill training, balance training,
aquatic therapy, and other assistive devices have been shown to provide positive
outcomes in gait variables. Treadmill training with and without body-weight support has
been shown to provide a more symmetrical gait pattern; however, the degree of symmetry
is not completely retained once the participant walks in an overground walking condition
(Brouwer et al., 2009; Hesse, 2003). Balance training is useful in strengthening the
paretic limb’s knee flexors and improving postural balance (Yavuzer et al., 2006). The
majority of the literature in this area explores the effectiveness of isolated gait training
interventions. Community or other innovative programs aimed at the stroke survivor
population are currently in demand. The creation of such programs have the potential to
improve health in stroke survivors and help reduce health care costs through prevention
of secondary health issues associated with decreased physical activity in this population
(Stuart et al., 2008).
15
Post-Stroke Physical Activity Manual
Stroke
Defining Stroke
A stroke is an injury to the brain and occurs when blood flow to part of the brain
stops; thus, depriving the brain of blood and oxygen (Hayes, 2012). The type of stroke
can be generalized into two categories, ischemic and hemorrhagic stroke. Ischemic
Stroke is a stroke caused by reduced blood flow to the brain, which may be attributed a
blood clot in the blood vessels or when blood vessels become too narrow blocking blood
flow, which results in brain damage. A hemorrhagic Stroke is a stroke caused by a blood
vessel that bursts causing blood leaks in the brain resulting in brain damage. There are
many risk factors for stroke. These factors include high blood pressure, diabetes,
atherosclerosis, tobacco use, alcohol use, high cholesterol, obesity, and sedentary lifestyle
(Hayes, 2012).
Stroke Lower Extremity Characteristics
The impact on the post-stroke patient’s ambulation can extend from acute and
sub-acute phases to chronic post-stroke phase. Motor impairments experienced by post-
stroke patients include spasticity, weakness, proprioceptive deficits, and impaired
selective motor control (Sullivan et al., 2009). Hemiparetic gait often results in the post-
stroke patient, which is characterized by weakness on one side of the body (Sullivan et
al., 2009; Yavuzer, Eser, Karakus, Karaoglan, & Stam, 2006). For example, post-stroke
hemiparetic patients exhibit foot drop during swing phase in the paretic leg, lack of initial
contact or heel strike, knee instability in the sagittal plane, and medio-lateral ankle
instability during stance phase (Yavuzer et al., 2006). Exaggerated postural sway in the
16
sagittal and frontal planes is also evident (Yavuzer et al., 2006). Pelvic hiking is also
seen in this population during the swing phase in the paretic limb as a result of the lack of
knee flexion (Chen & Patten, 2006). Sullivan et al. (2009) noted that compensations of
increased activity in the paretic hip flexor are in response to weak plantar flexors; this is
accomplished to increase walking speed. One study showed that knee flexors in the
hemiparetic limb have a role in predicting gait speed (Nasciutti-Prudente et al., 2009),
which is a measure of gait performance in post-stroke participants (Rao et al., 2008). The
degree of power output of the hemiparetic limb has also shown to have a relationship
with gait speed (McGinley et al., 2003). Disruption of motor neuron pathways and disuse
contribute to the paresis and further deconditioning (Sullivan et al., 2009). Rehabilitative
action is needed to improve the individual’s physical well-being. Lack of rehabilitation
in this population can lead to further reduction in strength and range of motion, and can
result in contractures (Sullivan et al., 2009). Peurala et al. (2007) suggest that gait
intervention programs should begin early because major improvements are made during
the first month post-stroke and may not be attained in later stages of gait rehabilitation.
Another characteristic of hemiparetic gait is a longer stance phase on the non-
paretic leg, which results in a shorter swing time on the paretic leg (Bensoussan et al.,
2006; Brouwer et al., 2009; Chen & Patten, 2006). The stance to swing phase ratio for
each of the legs shows the degree of symmetry in the individual’s gait pattern (Hesse,
2003). Step length asymmetry, and single support time asymmetry ratios between the
paretic and non-paretic leg, respectively, are also indicative of the degree of symmetry; a
greater ratio indicates a greater degree of asymmetry (Yavuzer et al., 2006). A longer
stance phase produces asymmetrical gait with greater body-weight distribution
17
experienced by the non-paretic leg (Bensoussan, Mesure, Viton, & Delarque, 2006).
Reduced walking speed, cadence (Hesse, 2003), and longer double support phase and gait
cycle are also exhibited in this population when compared with healthy individuals
(Nasciutti-Prudente et al., 2009). The literature indicates that post-stroke walking
rehabilitation programs that include task-specific training, lower-extremity strengthening,
and aerobic training are more effective than conventional neurophysiologic approaches
implemented by physical therapists (Sullivan et al., 2009).
The importance of walking function is important in the performance of activities
of daily living, independence, and reduction of secondary health issues (Patterson et al.,
2008). Secondary health issues may include reduced cardiovascular function, obesity,
osteoporosis, and decreased flexibility (Brouwer et al., 2009). Fall incidences decrease
the degree of physical activity in which the stroke survivor will engage. After a fall, the
individual may be less apt to participate in social engagements because of their fear of
falling; as a result, become less physically active and further deconditioned (Weerdesteyn
et al., 2008).
Professional Rehabilitation and Training Programs
Rehabilitation programs focus on functional training to improve activities of daily
living (ADL) to improve the stroke survivor’s level of independence (Lindahl et al.,
2008).
Treadmill
Treadmill training has gained increased recognition as a training intervention to
restore gait function (Brower et al., 2009; Chen, & Patten, 2006). Task-specific gait
training can be achieved using a treadmill to make improvements in gait speed and
18
endurance (Sullivan et al., 2009). Furthermore, the literature suggests improvement in
overground walking after treadmill training interventions in older participants with
hemiparetic gait (Lindquist et al., 2007). Treadmill walking produced greater inter-limb
symmetry when compared to overground walking (Brouwer et al., 2009; Chen & Patten,
2006). Total excursion maximum and minimum angles for the hip, knee, and ankle have
been found to be similar in over ground and matched treadmill walking speeds in post-
stroke participants (Brouwer et al., 2009).
Balance
Balance training has also been used and suggests improvements in postural
control and weight bearing on the paretic side during walking (Yavuzer et al., 2006).
Balance training programs aim to improve the individual’s posture and weight bearing on
the paretic limb (Yavuzer et al., 2006). The hip adductor and abductor muscles play a
key role in balance control (Yavuzer et al., 2006). EMG studies have reported decreased
activity in the hip adductor and abductor muscles in hemiparetic patients (Bensoussan et
al., 2006). The use of walking aids, such as canes, can further reduce the muscle activity
exhibited by the hip adductors because of the decreased force production, as a result of a
longer lever arm of the gluteus medius, yielding the same torque output (Hesse, 2003).
Yavuzer et al. (2006) found that targeting the hip adductor and abductor muscles is
important to reduce gait asymmetry, improve balance, and reduce the individual’s fall
risk. Hesse (2003) suggests that balance training should be implemented as task-specific
balance training because standing balance training does not yield improvements in gait
symmetry in hemiparetic individuals. Conversely, Sullivan et al. (2009) reports a strong
19
correlation between walking speed and standing balance post-stroke; especially in
individuals with more severe impairments.
Aquatic Therapy
Aquatic therapy has been shown to yield improvements and balance with
improved weight bearing and degree of knee flexion (Noh, Lim, Shin, & Paik, 2008).
Aquatic therapy offers post-stroke patients the opportunity to move with less effort and to
move in different movement planes independently (Noh et al., 2008). Aquatic therapy
using Ai Chi and Halliwick methods have been shown to improve postural balance and
knee flexor strength of the hemiparetic limb in post-stroke individuals in an eight week
aquatic intervention program (Noh et al., 2008). Improved postural balance and knee
flexor strength have been shown to positively affect gait outcome (Nasciutti-Prudente et
al., 2009). Postural control has been shown to affect weight bearing on the paretic leg,
which has a positive effect on gait (Yavuzer et al., 2006). In a study by Noh et al. (2008)
significant changes in knee flexor strength were evident in the aquatic therapy group
compared to a conventional therapy group; the changes in knee flexion resulted from the
repetitive flexion and extension movements during therapy. Peurala et al. (2007)
advocates that post-stroke gait training be task-specific and intensive. The use of aquatic
therapy enables the post-stroke individual to have repeated and intensive training that the
individual may perform individually where it would not be possible to work individually
using land-based techniques (Noh et al., 2008).
Physical Activity Barriers
Functional impairments also prevent this population from engaging in physical
activity. Post-stroke individuals note poor mobility, poor standing tolerance, fatigue, and
20
loss of leg, and hand function as their inability to return to active leisure (O’Sullivan &
Sullivan, 2010).
The resulting injuries of these falls have a physical and psychosocial impact.
After a fall, the individual may be less apt to participate in social engagements because of
their fear of falling; as a result, become less physically active and further deconditioned
(Weerdesteyn et al., 2008). Participation in physical activity has been linked with
decreases in depression and social isolation associated with stroke (Stuart et al., 2008).
The literature reports a lack of physical activity programs targeting the stroke
population (Rimmer et al., 2008). Community or other innovative programs have the
potential to improve health in stroke survivors and help reduce health care costs through
prevention of secondary health issues associated with decreased physical activity in this
population (Stuart et al., 2008).
One study reported varied barriers for physical activity programs designed for
stroke survivors among income groups. For example, in the group reporting less than
$15,000 annual income, 80 percent reported cost as a barrier and 70 percent reported
transportation as another critical barrier to physical activity programs whereas 50 and 40
percent, respectively were reported in the greater than $15,000 annual income group
(Rimmer et al., 2008).
Evidence-Based Physical Activity for Stroke Survivors
The literature supports the post stroke individual engaging in physical activity
exercises, even in conjunction with existing professional rehabilitation programs (Dean et
al., 2012). Exercise has been shown to maintain or improve bone health and reduce the
incidences of falls in this population (Eng et al., 2008). Customization of physical activity
21
programs is necessary to accommodate the special needs of the stroke survivor; as a
result, a reduction in some of the personal, environmental, and financial barriers (Rimmer
et al., 2008). Medical clearance should be obtained before beginning an exercise
program with the post-stroke population. Exercises should be introduced and progressed
gradually based on the tolerance of the stroke survivor. In addition, the survivor should
be provided with longer rest periods between exercises (Eng et al., 2008).
Cardiovascular Health
Improvements in cardiovascular health can be attained through exercise.
Exercises that improve cardiovascular health may yield improvements in other areas. For
example, treadmill and over-ground walking produced a 20 percent increase in over-
ground walking speed over a four-week training period (Macko et al., 2008). Improving
cardiovascular health through exercise has also yielded reduction in secondary health
problems such as heart disease and recurrent stroke (Eng et al., 2008) and osteoporosis.
Brisk walking and alternate stepping onto low risers with reducing arm support in the
FAME exercise program yielded improvements in cardiovascular health. Walking
duration began at ten minutes with an increase of five minute increments each week up to
thirty minutes. The goal of this program was for the post-stroke individual progress from
40 to 50 percent heart rate reserve (HHR) to 70 to 80 percent HHR in 10 percent
increments as tolerated by the individual (Galvin et al., 2011; Pang et al., 2005).
Balance
Fall risk is largely correlated with gait and balance deficits. Stroke survivors are
up to 4 times more likely to sustain a hip fracture compared to other populations (Dean et
al., 2012). These factors highlight the importance of balance training in the post-stroke
22
individual. Balance training has been used in post stroke rehabilitation and suggests
improvements in postural control and weight bearing on the paretic side during walking
(Yavuzer et al., 2006). One study reported employed a balance exercise that involved the
stroke individual walking parallel bars with hand support through an obstacle course for
twelve minutes. The obstacle course involved walking laterally, stepping over three steps,
and stepping over 10 cm-high boards. This study reported balance improvements in
stroke survivors when combined with strength training (Macko et al., 2008). The FAME
program implemented by Pang et al. (2005) also reported the implementation of an
obstacle course to improve balance. Balance training programs aim to improve the
individual’s posture and weight bearing on the paretic limb (Yavuzer et al., 2006). Other
sources of balance training involve balancing on wobble boards, foam, balance discs,
tandem walking, walking in different directions, kicking a ball with the paretic and/or
non-paretic leg, and toe raises (Pang et al., 2005).
Muscular Strength
One study discovered a 21 percent increase in over-ground walking distance in
individuals with stroke with a combined strength and aerobic training program (Macko et
al., 2008). Exercises such as, repetitive sit-to-stand exercises has been shown to reduce
the risk of falls in the post-stroke population (Noh et al., 2008), specifically the FAME
program suggests progressing the number of partial squats from 2 sets of 10 to 3 sets of
15 (Pang et al., 2005). Macko et al. (2008) suggest eight repetitions of each half-squats,
weight shift from leg to leg, leg-trunk flexion, and extension exercises, and turning in
place to improve lower extremity strength.
23
Bone Density
Mechanical loading has been shown to decrease bone mineral density (BMD).
Decrease in bone mineral density is reported in stroke survivors as the result of decreased
loading on the hemiparetic leg. Increased fall risk has been correlated with deceased
BMD (Pang et al., 2005). Exercise has been shown to improve bone health in the stroke
population (Eng et al., 2008; Pang et al., 2005).
24
Table 1.
Physical Activity Exercises Summary
Physical Activity Exercises Reference
Cardiovascular Treadmill and over-ground
walking
Obstacle course
Brouwer et al, 2009
Chen, & Patten, 2006
Galvin et al., 2011
Pang et al., 2005
Sullivan et al., 2005
Eng et al., 2008
Pang et. al., 2005
Balance Obstacle course
Balance on non-compliant
surfaces(on foam, wobble
board, balance disks)
Tandem walking
Walking in different directions
(forward, backward, lateral)
Stepping over 10-cm high
steps
Kicking a ball with both
affected and non-affected leg
Eng et al., 2008
Pang et al., 2005
Galvin et al., 2011
Pang et.al, 2005
Yavuzer et. al, 2006;
Pang et al., 2005
Eng et al., 2008
Pang et al., 2005
Pang et al., 2005
Muscular Strength Sit-to-stand
Bridging
Partial squats
Weight shift from leg to leg
Leg-trunk flexion, and leg
extension exercises
Pang et al., 2005
Bone Strength Mechanical loading
Eng et al., 2008
Pang et al., 2005
25
Exercise Samples
Medical clearance should be obtained before beginning an exercise program with
the post-stroke population (Eng et al., 2008; Pang et al., 2005). Exercises should be
introduced and progressed gradually based on the tolerance of the stroke survivor. In
addition, the survivor should be provided with longer rest periods between exercises (Eng
et al., 2008). Warning signs to stop physical activity include pain, discomfort, shortness
of breath, dizziness, fainting, and the individual requesting to stop activity (Dwyer &
Davis, 2005). Other warning signs to stop physical activity are falls, nausea, and
vomiting (Hayes, 2012).
Table 2.
Sample Exercise Program 1
Beginner – Duration 15-30 minutes
Exercise Repetitions Duration
Over ground walking --- 5-10 minutes
or as tolerated
Sit-to-stands 8-10 5-10 minutes
or as tolerated
Side-to-side weight shifts
(with support)
8-10 5-10 minutes
or as tolerated
26
Table 3.
Sample Exercise Program 2
Intermediate – Duration 30-45 minutes
Exercises Repetitions Duration
Over ground walking,
obstacle course, tandem
walking, walking in
different directions
(forward, backward,
lateral),
--- 10-15 minutes
or as tolerated
Sit-to-stand/partial squats,
bridging
10-15 10-15minutes
or as tolerated
Sit-to-stand/partial squats or
bridging
Side-to-side weight whifts
(with support )
10-15 10-15 minutes
or as tolerated
Table 4.
Sample Exercise Program3
Advanced – Duration 45-60 minutes
Exercises Repetitions Duration
Over ground walking
obstacle course, standing
balance (foam, wobble
board, balance disc),
tandem walking, walking in
different directions
(forward, backward, lateral)
--- 5-10 minutes
or as tolerated
Partial squats, bridging 2 sets x 10-15 repetitions 5-10 minutes
or as tolerated
Side-to-side and front-to-
back weight shifts,
leg-trunk flexion, and leg
extension exercises,
kicking ball with paretic
and non-paretic leg
2 sets x 10-15 repetitions 5-10 minutes
or as tolerated
27
How the Manual will be Utilized
The literature supports the need for community or home-based programs and cites
a lack of exercise programs catering to the stroke population (Dean et al, 2012; Eng et al.,
2008; Lindahal et al, 2008; Pang et al., 2005). The sedentary lifestyle commonly found
in the post-stroke population may result in a development of secondary health problems
and increases the individual’s risk for another stroke (Lindahal et al., 2008). This
illustrates the importance of catering physical activity resources to this population. The
evidence-based exercise examples provided in the manual serve as a guide to aid non-
clinicians, such as adapted physical activity students and caregivers, family responsible
for care of the post-stroke individual, and the post-stoke individual. Upon receiving
medical clearance, this manual can be used as a guide for the non-clinician to help the
stroke survivor return to physical activity in effort to reduce risks of secondary health
issues and increase independence.
28
Future Needs for a Manual and Updates
There is growing interest and need for community or home based programs aimed
at improving health in efforts to reduce secondary health issues in the stroke survivor
population (Dean et al, 2012; Eng et al., 2008; Lindahal et al, 2008; Pang et al., 2005). A
protocol for evidence-based physical activity for community or home based programs is
needed (Dean et al., 2012). A manual with current scientific findings can provide
background information and physical activity exercise samples for the post-stroke
individual that a non-clinician, such as adapted physical activity student, can help
implement. There will be a future need for updates to this manual with emerging
scientific data. Further research is necessary to determine effective exercise programs
that cater specifically to the stroke population to yield physical activity benefits, which
also aid in improving physical deficits (Lindahl et al., 2008). The need for other manuals
for the stroke survivor population are suggested to further discuss deficits and needs in
the upper extremities, as this manual focused on lower extremity deficits and physical
activity exercises.
29
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