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

References

Bensoussan, L., Mesure, S., Viton, J., & Delarque, A. (2006). Kinematic and kinetic

asymmetries in hemiplegic patients' gait initiation patterns. Journal of

Rehabilitation Medicine, 38(5), 287-294.

Brouwer, B., Parvataneni, K., & Olney, S. (2009). A comparison of gait biomechanics

and metabolic requirements of overground and treadmill walking in people with

stroke. Clinical Biomechanics, 24(9), 729-734.

Chen, G., & Patten, C. (2006). Treadmill training with harness support: Selection of

parameters for individuals with poststroke hemiparesis. Journal of Rehabilitation

Research & Development, 43(4), 485-497.

Dean, C., Rissel, C., Sharkey, M., Sherrington, C., Sharkey, M., Cumming, R., Lord, R.,

Barker, R., Kirkham, C., & O’Rourke, S. (2012). Exercise to enhance mobililty

and prevent falls after stroke: the community stroke club randomized trial.

Neurorehabilitation and Neural Repair, 1-9.

Dwyer, G., & Davis, S. (Eds.). (2005). Title of work: Capital letter also for subtitle. (2

Ed.). Philidelphia, PA: Lippincott Williams & Wilkins.

Eng, J., Pang, M., & Ashe, M. (2008). Balance, falls, and bone health: role of exercise in

reducing fracture risk after stroke. Journal Of Rehabilitation Research &

Development, 45(2), 297-313.

Galvin, R., Cusak, T., O’Grady, E., Murphy, T., & Strokes, E. (2011). Family-mediated

exercise intervention (FAME): evaluation of a novel form of exercise delivery

after stroke. Stroke Journal of the American Heart Association,42,

681-686.

30

Hayes, C. (2012). Essentials of stroke for healthcare assistants. British Journal Of

Healthcare Assistants, 6(4), 170-175.

Hesse, S. (2003). Rehabilitation of gait after stroke: Evaluation, principles of therapy,

novel treatment approaches, and assistive devices. Topics in Geriatric

Rehabilitation, 19(2), 109-126.

Lindahl, M., Hansen, L., Pedersen, A., Truelsen, T., & Boysen, G. (2008). Self-reported

physical activity after ischemic stroke correlates with physical capacity. Advances

In Physiotherapy, 10(4), 188-194.

Lindquist, A., Prado, C., Barros, R., Mattioli, R., da Costa, P., & Salvini, T. (2007). Gait

training combining partial body-weight support, a treadmill, and functional

electrical stimulation: Effects on poststroke gait. Physical Therapy, 87(9), 1144-

1154.

Macko, R., Benvenuti, F., Stanhope, S., Macellari, V., Taviani, A., Nesi, B., Weinrich,

M., & Stuart, M. 2008). Adaptive physical activity improves mobility function

and quality of life in chronic hemiparesis. Journal Of Rehabilitation Research &

Development, 45(2), 323-328.

McGinley, J., Goldie, P., Greenwood, K., & Olney, S. (2003). Accuracy and reliability of

observational gait analysis data: Judgments of push-off in gait after stroke.

Physical Therapy, 83(2), 146-160.

Nasciutti-Prudente, C., Oliveira, F., Houri, S., Rodrigues de Paula Goulart, F., Neto, M.,

& Teixeira-Salmela, L. (2009). Relationships between muscular torque and gait

speed in chronic hemiparetic subjects. Disability & Rehabilitation, 31(2), 103-

108.

31

Noh, D., Lim, J., Shin, H., & Paik, N. (2008). The effect of aquatic therapy on postural

balance and muscle strength in stroke survivors -- a randomized controlled pilot

trial. Clinical Rehabilitation, 22(10-11), 966-976.

O'Sullivan, C., & Chard, G. (2010). An exploration of participation in leisure activities

post-stroke. Australian Occupational Therapy Journal, 57(3), 159-166.

Pang, M., Eng, J., Dawson, A., McKay, H., & Harris, J. (2005). A community-based

fitness and mobility exercise program for older adults with chronic stroke: a

randomized, controlled trial. Journal Of The American Geriatrics Society, 53(10),

1667-1674.

Patterson, S., Rodgers, M., Macko, R., & Forrester, L. (2008). Effect of treadmill

exercise training on spatial and temporal gait parameters in subjects with chronic

stroke: A preliminary report. Journal of Rehabilitation Research & Development,

45(2), 221-228.

Peurala, S., Airaksinen, O., Jäkälä, P., Tarkka, I., & Sivenius, J. (2007). Effects of

intensive gait-oriented physiotherapy during early acute phase of stroke. Journal

of Rehabilitation Research & Development, 44(5), 637-648.

Rao, N., Chaudhuri, G., Hasso, D., D'Souza, K., Wening, J., Carlson, C., & Aruin, A. S.

(2008). Gait assessment during the initial fitting of an ankle foot orthosis in

individual with stroke. Disability & Rehabilitation: Assistive Technology, 3(4),

201-207.

Rimmer, J., Wang, E., & Smith, D. (2008). Barriers associated with exercise and

community access for individuals with stroke. Journal Of Rehabilitation Research

& Development, 45(2), 315-322.

32

Smith, P., & Thompson, M. (2008). Treadmill training post stroke: Are there any

secondary benefits? A pilot study. Clinical Rehabilitation, 22(10-11), 997-1002.

Stuart, M., Chard, S., & Roettger, S. (2008). Exercise for chronic stroke survivors: a

policy perspective. Journal Of Rehabilitation Research & Development, 45(2),

329-335.

Sullivan, K., Mulroy, S., & Kautz, S. (2009). Walking recovery and rehabilitation after

stroke. Stroke recovery & rehabilitation (pp. 323-342). New York, NY: Demos

Medical Publishing.

Weerdesteyn, V., de Niet, M., van Duijnhoven, H., & Geurts, A. (2008). Falls in

individuals with stroke. Journal of Rehabilitation Research & Development,

45(8), 1195-1213.

Yavuzer, G., Eser, F., Karakus, D., Karaoglan, B., & Stam, H. (2006). The effects of

balance training on gait late after stroke: A randomized controlled trial. Clinical

Rehabilitation, 20(11), 960-969.