What Is Intensity and How Can It Benefit Exercise Intervention in People With Stroke? A Rapid Review

Abstract

Background: Stroke is one of the major causes of chronic physical disability in the United Kingdom, typically characterized by unilateral weakness and a loss of muscle power and movement coordination. When combined with pre-existing comorbidities such as cardiac disease and diabetes, it results in reductions in cardiovascular (CV) fitness, physical activity levels, functional capacity, and levels of independent living. High-intensity training protocols have shown promising improvements in fitness and function for people with stroke (PwS). However, it remains unclear how intensity is defined, measured, and prescribed in this population. Further, we do not know what the optimal outcome measures are to capture the benefits of intensive exercise.Aim: To understand how intensity is defined and calibrated in the stroke exercise literature to date and how the benefits of high-intensity training in PwS are measured.Methods: A rapid review of the literature was undertaken to provide an evidence synthesis that would provide more timely information for decision-making (compared with a standard systematic review). Electronic databases were searched (including Medline, PubMed, CINAHL, and Embase for studies from 2015 to 2020). These were screened by title and abstract for inclusion if they: (a) were specific to adult PwS; and (b) were high-intensity exercise interventions. Eligible studies were critically appraised using the Mixed Method Appraisal Tool (MMAT). The data extraction tool recorded the definition of intensity, methods used to measure and progress intensity within sessions, and the outcomes measure used to capture the effects of the exercise intervention.Results: Seventeen studies were selected for review, 15 primary research studies and two literature reviews. Sixteen of the 17 studies were of high quality. Nine of the primary research studies used bodyweight-supported treadmills to achieve the high-intensity training threshold, four used static exercise bikes, and two used isometric arm strengthening. Five of the primary research studies had the aim of increasing walking speed, five aimed to increase CV fitness, three aimed to improve electroencephalogram (EEG) measured cortical evoked potentials and corticospinal excitability, and two investigated any changes in muscle strength. Although only one study gave a clear definition of intensity, all studies clearly defined the high-intensity protocol used, with most (15 out of 17 studies) clearly describing threshold periods of high-intensity activity, followed by rest or active recovery periods (of varying times). All of the studies reviewed used outcomes specific to body structure and function (International Classification of Functioning, Disability, and Health (ICF) constructs), with fewer including outcomes relating to activity and only three outcomes relating to participation. The reported effect of high-intensity training on PwS was promising, however, the underlying impact on neurological, musculoskeletal, and CV systems was not clearly specified.Conclusions: There is a clear lack of definition and understanding about intensity and how thresholds of intensity in this population are used as an intervention. There is also an inconsistency about the most appropriate methods to assess and provide a training protocol based on that assessment. It remains unclear if high-intensity training impacts the desired body system, given the diverse presentation of PwS, from a neuromuscular, CV, functional, and psychosocial perspective. Future work needs to establish a clearer understanding of intensity and the impact of exercise training on multiple body systems in PwS. Further understanding into the appropriate assessment tools to enable appropriate prescription of intensity in exercise intervention is required. Outcomes need to capture measures specific not only to the body system, but also level of function and desired goals of individuals.

Cognitive and Linguistic Benefits of Aerobic Exercise: A State-of-the-Art Systematic Review of the Stroke Literature

“…Regarding intervention characteristics, across all studies, exercise intensity (i.e., level of effort) and modality (e.g., cycling, walking, stepping) were highly variable, with no discernable pattern differentiating studies reporting positive vs. null cognitive outcomes. Of note, five positive and three null outcome studies failed to report any information regarding exercise intensity, and the remaining studies defined and monitored intensity levels in a variety of different manners (e.g., relative to maximal heart rate, maximal oxygen consumption, or rating of perceived exertion), mirroring a general lack of consensus across the stroke rehabilitation literature ( 82 ). Likewise, no patterns emerged for studies reporting group vs. individual exercise programs, nor supervised vs. unsupervised exercise sessions, supporting the idea that the beneficial effects of exercise are dissociated from the social engagement inherent in group settings [e.g., ( 83 )].…”

Designing for usability: development and evaluation of a portable minimally-actuated haptic hand and forearm trainer for unsupervised stroke rehabilitation

“…Yet, while lower values of the RTLX are preferable (except the inverted Performance item) for rehabilitation device interfaces (Ranzani et al, 2021 ), it can not be generally stated that mental, physical, and temporal demand, as well as effort, should be as low as possible for games or exercises. On the contrary, for example, to achieve a high exercise intensity, a larger (perceived) effort is typically desirable (Eston et al, 1987 ; Church et al, 2021 ). To promote neuroplasticity—which is the ultimate goal of this device—the performance should be high enough to keep the user motivated, but low enough to provide room for improvement (Guadagnoli and Lee, 2004 ).…”

10- or 30-minute treadmill exercise rescues motor behaviors through inhibiting apoptosis in a rat MCAo model

“…Stroke, one of the leading causes of morbidity and mortality, is neurological damage caused by ischemia and hemorrhage, resulting in impeded blood supply to the central nervous tissue of the brain (1)(2)(3)(4). Worldwide, 70 million people suffer strokes each year, including ischemic stroke, which is caused by insufficient blood flow and accounts for 80% of stroke patients (1)(2)(3).…”

“…Stroke, one of the leading causes of morbidity and mortality, is neurological damage caused by ischemia and hemorrhage, resulting in impeded blood supply to the central nervous tissue of the brain (1)(2)(3)(4). Worldwide, 70 million people suffer strokes each year, including ischemic stroke, which is caused by insufficient blood flow and accounts for 80% of stroke patients (1)(2)(3). Ischemic stroke, also called cerebral infarction, triggers the formation of brain tissue necrosis or death, which activates inflammatory responses and apoptotic pathways, surrounded by a peripheral reversible infarction area (3).…”