Introduction

Stroke, often called a Cerebrovascular Accident (CVA), is a sudden central nervous system impairment in which the flow of oxygen and nutrients to the brain is halted through a blood clot (ischemia) or bleeding (hemorrhage). It is the third leading cause of death in the United States and the leading cause of disability. Four million stroke survivors are living in the United States, and more than 730,000 Americans experience a stroke each year. An individual who has experienced a stroke can have a wide range of limitations from minimal to severe. The side of the brain where the stroke took place controls the opposite side of the body. So if an individual experiences a stroke on the left side of their brain the right side of their body will most likely be effected. Individuals can experience a number of secondary conditions as well including paraplegia, hemiplegia, decreased balance, and speech and memory issues to name a few.

Risk Factors Associated with Stroke

Individuals who have experienced a stroke are at a greater rick of developing several associated secondary health and wellness conditions, including:

• Hypertension
• Coronary artery disease
• Hyperlipidemia
• Diabetes
• Obesity
• High amounts of alcohol, caffeine, and nicotine

Importance of Exercise

In addition to improving overall cardiovascular fitness, strength, and flexibility, exercise can decrease risk factors for a second stroke through decreasing hypertension and body fat and improving the blood lipid profile and glucose regulation. Exercise can also help increase function in the extermities that were affected by the stroke and increase the ease of activities of daily living. Including a well-rounded fitness program that includes cardiovascular, muscular strength, and flexibility can help increase function in all areas of life.

There are several types of exercise that can benefit individuals who have had a stroke, both in their own and in tandem as part of a holistic exericse program. These include:

• Cardiovascular exercises to help decrease hypertension and body fat and to improve glucose regulation, blood lipid profile, and overall fitness
• Strength exercises to support both involved and uninvolved limbs
• Flexibility exercises to increase range of motion and to prevent contractures
• Coordination and balance exercises to improve daily living activities

For results to be evident, a complete program of cardiovascular, strength and flexibility components should be performed for four to six months.

Safety Measures

It is imperative to check with your primary physician before starting an exercise program; an exercise stress test is highly recommended to ensure that your heart is in condition to exercise. Once you have gotten physician consent and recommendations, consider the following additional safety measures as you begin to exercise

• Use a trained exercise professional to help establish a safe and effective program. Note that before beginning a full exercise program, motor recovery for your involved side should be nearly complete (six to 12 months post-injury).
• Are you prepared for your workout? Have you taken necessary medications (i.e., hypertension medications, water pills)? Are you drinking enough water and other fluids? Are you wearing proper exercise clothing, such as cotton material that breathes and a good pair of exercise shoes?
• Monitor your blood pressure periodically throughout an exercise program. Stop exercising if your blood pressure rises above 200/110 mmHg.
• Know how the medications you are taking affect your body’s ability to exercise. Some may affect your heart rate and your trainer needs to be aware of that.
• Mental confusion: Ask your exercise physiologist to repeat any information or instructions you do not understand or cannot remember.
• Be aware of occurrences of orthostatic hypotension, which is dizziness, nausea and lightheadedness from suddenly sitting or standing up. Lie in a supine position with feet elevated until the symptoms have passed, avoid quick movements and drink plenty of water.
• Balance: Make sure you have adequate support while using the machines to avoid dangerous falls.
• Spasticity: Consult with your exercise physiologist as to the extent a spastic muscle can be strengthened and/or stretched. Avoid increasing abnormal muscle tone. Resistance training can be indicated for spastic muscles if you have full isolated control of all movements. Immediately stop exercises that limit movement.
• Reciprocal inhibition: If muscle groups are not functional because of spasticity, the opposing muscle groups may be strengthened and help normalize the spasticity. For example, tricep muscles may be strengthened to support spastic bicep muscles. Any muscle groups incapable of being strengthened should be stretched. Spasticity can affect the respiratory muscles of the involved side. Cardiovascular exercise and deep rhythmical breathing can help strengthen respiratory muscles. Note that spasticity and spasms may increase following exercise/strengthening of the noninvolved side and should not last.

Cardiovascular Training Guidelines

• Set an exercise pace that feels good to you. Rate your level of exertion by the Rate of Perceived Exertion scale (range of 6 to 20 where 6 = very, very light, and 20 = very, very hard); 11 to 14 is a good target zone.
• Take slow, deep breaths and ‘think tall’ in order to maintain good posture.
• Vary the cardiovascular workout by using a number of different machines, depending on the function of the affected limbs. If you have some muscle control in the affected upper limb, use a hand splint to row or pull. Foot straps can help to hold a spastic lower limb in place.
• General cardiovascular exercise should be performed 3-5 days per week for 20 to 60 minutes per session, using shorter intervals of work as needed. If necessary, perform these sessions under the guidance of a physician or exercise physiologist.
• If you have decreased sensation in the affected side, shift your sitting position every 10 to 15 minutes to increase circulation and prevent pressure sores.

Strength Training Guidelines

• Hypertension and osteoporosis are special concerns when performing strength training programs. Talk with your primary physician before starting a program.
• Do not hold your breath while strength training. Instead, exhale or breathe out while pushing the weight up or out and inhale or breathe in while letting the weight down or in. While taking slow, deep breaths, ‘think tall’ to maintain your posture.
• Reciprocal inhibition may help strengthen spastic limbs. For example, if you have spastic bicep muscles you may want to strengthen the opposing tricep muscles.
• If you have muscle control on the affected side, you can use a splint or mitt to help with grip and performing exercises with weights.
• Begin strength training at a weight equal to 70% of a 10-repetition maximum. (This is 70% of the weight that you can lift in that exercise only ten times before you fatigue.) When you can use this weight for 25 repetitions in two consecutive sessions, increase the weight 10%.
• Strength training should be performed two to three days per week, doing three sets of eight to 12 repetitions per exercise. 8-10 different exercises incorporating each of the major muscle groups is a good target.
• A variety of equipment can be used including strength training machines, hand-held weights, plastic tubing and ‘toys’ (medicine balls, plastic buoys).

Flexibility/Functionality Training Guidelines

Training should be performed daily for 10 to 15 minutes.

• Training should be performed after every cardiovascular and strength session.
• Every muscle group used in a workout should be stretched thoroughly after the session. Always stretch both the affected and unaffected sides.
• Spend more time on tight muscle groups.
• Stretches should be held for a minimum of 15 to 30 seconds for maximum benefit.
• Stretching should not be painful, but there may be a feeling of slight discomfort.
• As much as possible, use the affected side for activities of daily living (ADL) such as eating, combing your hair or dialing a phone number.

Recommended stretches include:

• Arm and back-of-the-arm stretches
• Calf and hamstring stretches
• Stretches to improve balance impairments

Ways to develop fine motor skill sinclude:

• Artistry/graphic arts: Drawing figures such as circles or squares
• Multiple line dimension (line through square)
• Simple figures: Star, shoe
• Medicine balls
• Video games: Play games with joysticks that have a progression of difficulty.