Treating Diseases with Sports and Exercise: a Report About Endurance Training for Stroke Patients

Introduction

The knowledge about the effectiveness of interventions for stroke patients, which improve the physical fitness is very little. According to Hoeß, Schupp, Schmidt and Gräßel (2008) standard guidelines for rehabilitation of stroke patients don’t exist in Germany. Generally accepted information about content, duration and frequency of interventions for stroke patients are still missing. This report will aim to illustrate the cur- rent scientific circumstances in the field of endurance interventions for stroke patients. Subsequently, it will describe an approach for endurance training with stroke patient.

In consequences of the rising life expectancy the number of strokes increases continuously. The World Health Organization (WHO) defines a stroke as an interruption of the supply of nutrients and oxygen to the brain, “causing damage to the brain tissue” (WHO, 2018). In industrialized countries stroke is the third most cause of death. In Germany approximately 250,000 people suffer a stroke every year. About 175,000 survive the acute phase, but a full recovery is rarely.

Symptoms and Problems of Stroke Patients

“The majority of stroke survivors have residual impairments caused by the stroke, such as hemiparesis, spasticity, cognitive dysfunction, and aphasia”. Typically, patients suffer from different impairments in variety severities and combinations, for example dizziness, double vision, dysphagia or ataxia. Six to twelve months after a stroke, stroke survivors have substantially diminished cardiorespiratory fitness. Low fitness leads to a reduction in mobility (Gersten & Orr, 1971), which compounds the deleterious impact on functional capacity after a stroke. It also promotes cardiovascular risk. In addition, up to 75 percentage of stroke survivors have a coexisting cardiac disease.

With the information of the previous paragraph in mind, avoiding a vicious circle of decreased activity and greater exercise intolerance especially for stroke patients seems to be important for preventing from secondary symptoms. Billinger et al. (2014) mention, that a low activity level “leads to secondary complication as reduced cardiorespiratory fitness, increased fatigability, muscle atrophy/weakness, osteoporosis, and impaired circulation to the lower extremities in stroke survivors”.

Furthermore, the disease and their sequela can have a massive negative psychological impact. Likely reasons for limited exercise participation are: a lack of awareness, that exercise is desirable or feasible, as well as the lack of access to resources and structured exercise sessions. Consequently, these facts should be paid attention to in the development of an endurance exercise session. Moreover, it is important to consider stroke patients achieve significant lower maximal workloads, heart rate and blood pressure responses (King et al., 1989). In due consideration of this chapter, the following chapters will elaborate an approach for endurance training for stroke survivors.

Development of an Exercise Lesson for Stroke Patients

The American Heart Association (AHA) and American Stroke Association (ASA) published, that “the evidence strongly supports the benefits of physical activity exercise for stroke survivors”. As a main result of a Cochrane Review from 2009, cardiorespiratory training involving walking, improved walking, endurance and speed, just as reduced dependence during walking (Saunders et al., 2009). Particularly, endurance training is mentioned as an exercise mode, which significantly improves exercise tolerance during continuous activity. Moreover, aerobic exercise programs have shown to be effective in enhancing glucose regulation along with improve blood pressure and arterial functions.

Steib and Schupp (2012) describe, that they were able to identify twelve randomized controlled trails, which examined endurance training, strength training or a combination of both interventions with stroke patients. The Cochrane Review includes 629 participants from eleven trails, in which only cardiorespiratory training was examined (Saunders et al., 2009). Important results, that authors of scientific publications conclude, are that an endurance intervention shows effects in improving speed, tolerance and independence during walking, overmore aerobic capacity, walking function, lower extremity strength (Gordon et al., 2013), sensorimotor functions along with cardiorespiratory fitness during subacute and chronic phase of stroke recovery.

Additionally, endurance training has been presented as a significant positive influence on cardiovascular risk factors, which is a profound component of the secondary prevention. In essence, stroke survivors seem to benefit from an endurance training. Although, it is also often mentioned, that further research is needed. It exists a need for larger trails with a greater range of stroke severity (Saunders et al., 2009). Furthermore, “It was not possible to determine the effect of fitness training variables, such as ‘dose’ or type of training”.

Concept of an endurance lesson for stroke patients In this chapter, the scientific findings will be illustrated in relationship to an endurance intervention. Precedent, this developed exercise lesson will be conform to the recommendations of the American Stroke Association, which means a trainings frequency of three days per week with a duration of 30 to 60 minutes per session. The determined trainings-intensity is moderate (40-70% peak exercise capacity (VO2peak)) and depending on the participants functional capacity.

Use of methodological-didactical principles Regarding, the methodological-didactical principles, the sports program “need to be customized to the tolerance of the patient, stage of recovery, environment, available social support, physical activity preferences, and their specific impairments, activity limitations, and participation restrictions”. Every planned exercise lesson consists of constant and renewable parts. One of the biggest motivations for stroke patients to participate in a sports program is the possibility of meeting other stroke survivor.

Therefore, every lesson starts with a collective greeting and warm-up, in which communication is explicit permitted and desirable. During this part participants get asked after their current well-being, in this way the exercise instructor can make out if he should to take care of someone or specific circumstances he has to keep an eye on. Both the greeting and the warm-up always follow the same structure. So, they are a type of ritual for the participants and the exercise lessons are developed from the known to the unknown. The main part consists of weekly modified endurance training in combination with different key aspects. So, it follows Saunders et al. (2009) recommendation of the concept of training specificity. For example, coordination, balance, cognitive functions or walking abilities can be represented in the main part.

Every main part is structured from simple to more complex and from easy to more difficult tasks. For instance, with a focus on coordinative functions the exercises become more difficult, by increasing the intensity, putting participant under time pressure or minimizing a target area. Dual-tasks, instable undergrounds or opposite movements of different parts of the body also increase the complexity during the main part. Likewise, these two methodological-didactical principles are also applied in a whole trainings session.

The same topic of the main part will be applied for one week, three lessons. So, one exercise consists of three in succession structured lessons. From throwing scarves to throwing balloons to throwing balls is a possibility to increase the complexity from the first to the third lesson of a session. Increasing the duration of the main part designs it more difficult and by recreating exercise from the last lesson, it again follows from known to unknown.

The following cool-down isn’t that difficult and complex as the main part. Every part of the lesson should be able to execute with a walking stick, walking frame or wheel chair as well. The exercises are also designed for patients with different severities of walking disabilities to ensure that every individual can participate the program. Moreover seat-accommodations are always provided for training on an individual appropriated intensity.

Endurance training is feasible for stroke patients. An endurance program is not only feasible in the early stage after a stroke, but also many years after a mild cerebrovascular accident cardiorespiratory training is feasible and can result an increased aerobic capacity. Although “exercise is not without risks, and although adverse events are not reported systematically in the literature, the recommendation that individuals with stroke participate in an exercise program is based on the premise that the benefits outweigh these risks.”

Conclusion

In conclusion, the foremost priority in developing and practicing an endurance training with stroke patients is to minimize the potential adverse effects via appropriate designing and monitoring the sports program.

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