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Background: There is increasing evidence for the beneficial effects of exercise training in stroke survivors. In order to reach the desired training effects, exercise training principles must be considered as this ensures the prescription of adequate exercises at an adequate dose. Moreover, exercise training interventions must be designed in a way that maximizes patients' adherence to the prescribed exercise regimen. The objectives of this systematic review were (1) to investigate whether training principles for physical exercise interventions are reported in RCTs for sub-acute and chronic stroke survivors, (2) to evaluate whether the RCTs reported the prescription of the FITT components of the exercise interventions as well as (3) patients' adherence to this prescription, and (4) to assess the risk of bias of the included studies.
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Methods: We performed a systematic review of RCTs with exercise training as the primary intervention and muscular strength and/or endurance as primary outcomes. The Cochrane library's risk of bias (ROB) tool was used to judge the methodological quality of RCTs.
Conclusions: Incomplete and inconsistent reporting of (1) training components, (2) underlying exercise training principles and (3) patient adherence together with (4) a broad variation in the methodological quality of the included RCTs limit both the utility and reproducibility of physical exercise programs in stroke patients.
Exercises designed to strengthen muscles involved in respiration, phonation, and articulation play a key role in the remediation of voice and swallowing disorders. This article presents exercise physiology principles that are beginning to be used by a small group of speech and swallowing researchers to undergird their efficacy-based studies of exercise-based therapy. Three principles--contraction type, task specificity, and overload--are used to compare past exercise-based therapies with present therapies. Comparisons are made between today's methods and Oskar Guttmann's (1893) principles for strengthening muscles of respiration, Emil Froeschels' (1944) therapy to improve laryngeal function, and the myofunctional therapy of the 1960s to improve swallowing and articulation.
Exercise is one of the most underutilized treatment options in modern American healthcare which places an emphasis on medications and procedures. The benefits of exercise have been researched and documented by many groups and agencies over the past three decades. The American College of Sports Medicine (ACSM),1 U.S. Centers for Disease Control and Prevention2, the U.S. Surgeon General, and the National Institutes of Health3 have issued landmark publications on physical activity and health.1,3,4 An exercise program that includes aerobic, resistance, flexibility, and neuromotor training is indispensable to improve and maintain physical fitness and health.4 Despite this, physical inactivity has been cited as one of the greatest public health threats of the 21st century.5
There are several methodologies to exercise prescription. One of the easier methods is the Frequency, Intensity, Time, and Type (FITT). The ACSM also recommends FITT-VP (Frequency, Intensity, Time, Type, Volume, and Progression). Utilizing these methodologies parallels writing a traditional medication prescription. Each component of the prescription provides a patient with specific information to incorporate aerobic, resistance, flexibility, and neuromotor exercise training into a fitness program.14,6
A meta-analysis in 2016 quantified the dose-response association between physical activity and five chronic diseases (Diabetes, Ischemic Heart Disease, Ischemic stroke, Breast and Colon Cancer). They found that higher levels of total physical activity, compared to current minimums recommended by the WHO and ACSM, were associated with lower risk for all outcomes.3 However, it should be noted that the dose-response relationship between volume and health benefits is curvilinear with the greatest return on investment at lower levels of activity and decreasing return of health benefits at higher levels of activity.11
While the majority of the recommendations for exercise are targeted at the generally healthy adult or youth population, evidence suggests that specified exercise therapy prescriptions are beneficial for patient populations with certain co-morbidities. Guidelines and recommendations are available for chronic diseases such as diabetes, obesity, arthritis, peripheral arterial disease, COPD, coronary artery disease, multiple sclerosis, and cancer. Some of these diseases along with other specific conditions will be discussed below.
The benefits of physical activity on cardiorespiratory health are extensively well-documented.4 Heart disease and stroke risks can be dramatically decreased with exercise. Regular aerobic exercise decreases arterial stiffness, reduces blood pressure, increases HDL, decreases LDL, and decreases resting heart rate. Exercise is known to decrease all-cause mortality in those with coronary artery disease.4,21 But what is often overlooked are the benefits of the addition of resistance training to aerobic exercise. Resistance training and increasing skeletal muscle mass has similar effects as aerobic exercise and can complement the effects to further reverse disease and improve cardiovascular health.22 Historically, several studies identified concerns that resistance training and strengthening exercises alone may increase arterial stiffness. However, recent studies have been inconclusive or contradictory by demonstrating actual improvement in arterial stiffness.23
Results from the HF-ACTION trial (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) suggest that exercise therapy reduces cardiac mortality and hospitalizations in patients with coronary heart disease and that exercise therapy may be safely conducted in certain heart failure populations.24 A recent meta-analysis found a reduction in the risk of re-hospitalization due to heart failure and improvements in health-related quality of life following exercise interventions.25,26
The American Heart Association and the American Stroke Association have provided a detailed report on guidelines for prescribing exercise for stroke survivors across all stages of recovery. Points of emphasis include low- to moderate-intensity aerobic activity, muscle-strengthening activity, and reduction of sedentary behavior.26 In terms of specific types of exercise for this patient population, community cycling exercise programs have been shown to significantly improve sit-to-stand capacity, activities of daily living, psychosocial functioning, energy, and depression.27 A recent study also found that core stability exercises were beneficial in improving trunk control, core muscle strength, standing weight-bearing symmetry, and balance confidence of ambulatory patients with chronic stroke.28 Additionally, forced, rather than voluntary, aerobic exercise can lead to enhanced motor skill acquisition when done prior to upper-extremity repetitive task practices.29 Other specific exercise prescriptions being evaluated for stroke survivors include HIIT and physical exercise in real and virtual environments.30,31
A review on exercise therapy for patients with multiple sclerosis (MS) found that combining aerobic training, strength training, and yoga yielded improvements in balance, dynamic gait, and symptoms of fatigue.32 Resistance training programs have also been shown to improve lower limb isometric strength and functional capacity in people with MS.33 Another review of exercise in neuromuscular disease (NMD) summarizes studies and information about a variety of neuromuscular conditions. Some basic recommendations for patients in this population include exercising carefully under physician supervision and targeting of certain muscles and breathing exercises rather than whole body aerobic conditioning. These recommendations include non-ambulatory individuals with NMD.34,15 All in all, the current literature continues to confirm the benefits of exercise in MS patients,35,36 but the absence of a conceptual framework and toolkit for translating this into practice remains a limiting factor in its implementation.37
The traditional advice to rest during pregnancy has changed, with current advice recommending a more active pregnancy.44 Regular exercise during pregnancy promotes overall wellness and may reduce hypertensive disorders of pregnancy and gestational diabetes.45 The American College of Obstetricians and Gynecologists recommends an exercise program of moderate-intensity exercise for at least 20-30 minutes per day on most or all days of the week for women with medical obstetric complications being monitored closely by their obstetrician.45,46 The PARmed-X for Pregnancy is a tool that may be utilized by the healthcare provider to medically screen pregnant women for exercise therapy, track their progress with exercise, and monitor for indications to stop exercise.47
Long COVID syndrome (LCS) has become readily apparent in patients previously infected with COVID. LCS is defined as symptoms lasting more than 12 weeks post COVID infection with the most common symptoms being breathlessness and fatigue.55 It has been proposed that moderate activity promotes a healthy immunological response to infection, and possibly suppresses autoimmune activity in the absence of infection, whereas reduced activity impairs immune response to infection.56 Various studies have demonstrated that different combinations of physical, aerobic, cardiopulmonary parameters, fatigue, cognition, perceived physical and mental health, depression and anxiety in LCS patients.57,58,59 However, further research with large-volume and long-term studies must be completed as there is currently no clear guideline for exercise rehabilitation in patients with LCS. Regular exercise in these patients is important and can help return them to their prior level of function while promoting daily activities, independent living, and an increased quality of life.59 152ee80cbc