Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations

Abstract

Knowledge gaps exist in how we implement aerobic exercise programs during the early phases post-stroke. Therefore, the objective of this review was to provide evidence-based guidelines for pre-participation screening, mobilization, and aerobic exercise training in the hyper-acute and acute phases post-stroke. In reviewing the literature to determine safe timelines of when to initiate exercise and mobilization we considered the following factors: arterial blood pressure dysregulation, cardiac complications, blood-brain barrier disruption, hemorrhagic stroke transformation, and ischemic penumbra viability. These stroke-related impairments could intensify with inappropriate mobilization/aerobic exercise, hence we deemed the integrity of cerebral autoregulation to be an essential physiological consideration to protect the brain when progressing exercise intensity. Pre-participation screening criteria are proposed and countermeasures to protect the brain from potentially adverse circulatory effects before, during, and following mobilization/exercise sessions are introduced. For example, prolonged periods of standing and static postures before and after mobilization/aerobic exercise may elicit blood pooling and/or trigger coagulation cascades and/or cerebral hypoperfusion. Countermeasures such as avoiding prolonged standing or incorporating periodic lower limb movement to activate the venous muscle pump could counteract blood pooling after an exercise session, minimize activation of the coagulation cascade, and mitigate potential cerebral hypoperfusion. We discuss patient safety in light of the complex nature of stroke presentations (i.e., type, severity, and etiology), medical history, comorbidities such as diabetes, cardiac manifestations, medications, and complications such as anemia and dehydration. The guidelines are easily incorporated into the care model, are low-risk, and use minimal resources. These and other strategies represent opportunities for improving the safety of the activity regimen offered to those in the early phases post-stroke. The timeline for initiating and progressing exercise/mobilization parameters are contingent on recovery stages both from neurobiological and cardiovascular perspectives, which to this point have not been specifically considered in practice. This review includes tailored exercise and mobilization prescription strategies and precautions that are not resource intensive and prioritize safety in stroke recovery.

Mobility After Stroke: Relearning to Walk

“…This result is in line with results in some animal studies, which show that early intensive training leads to additional damage of tissue at risk close to the lesion site (e.g., Humm et al 1998). Marzolini et al (2019) have studied this question in more detail and argue that initial therapy sessions should be brief, and cerebral hypotension should be avoided. Furthermore, as stroke can also affect the function of the heart, possible cardiac manifestations should be kept in mind (Marzolini et al 2019).…”

“…They further recommend "patients should participate in aerobic exercise at least 3 times weekly for a minimum of 8 weeks, progressing as tolerated to 20 minutes or more per session, exclusive of warm-up and cooldown" and "heart rate and blood pressure should be monitored during training to ensure safety and attainment of target exercise intensity." More detailed recommendations for patient safety are given by Marzolini et al (2019).…”

“…Marzolini et al (2019) have studied this question in more detail and argue that initial therapy sessions should be brief, and cerebral hypotension should be avoided. Furthermore, as stroke can also affect the function of the heart, possible cardiac manifestations should be kept in mind (Marzolini et al 2019). Thus, during the first 24 h, mobilization should be performed cautiously even in seemingly fit patients and exercise intensity should be light in the first days, slowly increasing to moderate.…”

“…Thus, during the first 24 h, mobilization should be performed cautiously even in seemingly fit patients and exercise intensity should be light in the first days, slowly increasing to moderate. Specific clinical guidelines based on recovery stages from neurological and cardiovascular perspectives are provided by Marzolini et al (2019).…”

Comprehensive Evaluation of the Oral Health Status, Salivary Gland Function, and Oxidative Stress in the Saliva of Patients with Subacute Phase of Stroke: A Case-Control Study

“…Since stroke is a serious worldwide health problem, there is an urgent need to develop new diagnostic and therapeutic methods. The phases of stroke are divided up into hyper-acute (from onset to first 24 h), acute (1–7 days), early subacute (7 days to 3 months), late subacute (3 to 6 months) and chronic stroke phase (over 6 months) [ 3 , 4 ]. The mechanisms thought to play a role during the subacute phase involve the resolution of the decrease in hypometabolism of structurally normal regions remote from the infarct due to disruption of a functional pathway to those regions [ 5 ].…”