Exercise after stroke
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2795 (Published 28 July 2009) Cite this as: BMJ 2009;339:b2795
All rapid responses
Despite the amount of published information which shows that
depression is associated with impaired cerebral blood flow, it is not
recognised clinically. Because stroke is the probable consequence of the
adverse effects of hyperviscous blood on blood flow, which remains in the
post-stroke period, it is not surprising that depression should accompany
stroke.
Therefore, if the blood viscosity problem is addressed then the
functional status of the patient should be improved and the depression
would be abolished.
Competing interests:
None declared
Competing interests: No competing interests
Mead has done well to describe the positive effects of exercise after
stroke [1], while commenting on Boysen et al’s publication on instructions
to improve activity after stroke [2]. One other positive effect of
exercise in stroke patients is its positive effect in giving some degree
of purpose to patients, and hence its positive effect in combating
depression, which, because of the loss of function, and hence of purpose
in life is very common in post-stroke patients. The incidence of post
stroke depression is considerable, with studies showing that the rates can
vary from 25% to 50% [3][4].
Indeed depression in stroke can lead to a poor prognosis and mortality in
stroke patients who suffer from depression is 13% higher than in those
who are not depressed [5].
Stroke causes a loss of function, and it is the realization of that loss
which makes patients with stroke depressed. If exercise can help restore
the patient to functioning, so that he can begin, within the limitation of
his disability, to develop interests in life, then the depression will be
ameliorated. This therefore needs to be a key aim in developing exercise
programs for post-stroke patients. The judicious use of antidepressants
may help, but exercise, delivered in a positive way to encourage the
development of new interests and skills, is key to the treatment of
depression in stroke patients.
Such is the importance of this issue, and the risk of not identifying and
treating depression in post-stroke patients, that we would recommend a
simple tool for the assessment of stroke patients, such as PHQ 9 [6] as a
useful outcome measure to be included in any further development of
Boysen’s study.
References
[1] Mead Exercise after Stroke BMJ 2009 ;339:b2795
[2] Boysen et al ExStroke Pilot Trial of the effect of repeated
instructions to improve physical activity after ischemic stroke: a
multinational randomized controlled clinical trial.BMJ 2009;339:b2810
[3] Astrom M et al (1993). Major depression in stroke patients. A 3 year
longitudinal study, Stroke. 24(7): 976-82
[4] Berg A et al (2003).Poststroke depression: an 18 month follow up.
Stroke. 34 (1):138
[5] Williams LS et al Depression and Other Mental Health Diagnoses
Increase Mortality Risk After Ischemic Stroke Am J Psychiatry, Jun 2004;
161: 1090 - 1095.
[6] Williams LS et al (2005). Performance of the PHQ-9 as a screening tool
for depression after stroke. Stroke. 36(3): 635-8
Competing interests:
None declared
Competing interests: No competing interests
According to Andrew Franks, "Exercise needs to be seen in perspective
- as a part of a co-ordinated community-based rehabilitation programme for
those whose post-stroke impairment requires it." But it is difficult to
accept that a community-based programme is needed, without a clear
understanding of the physiological benefits of exercise.
There are several reports which show that regular, low intensity
exercise lowers blood viscosity. This is relevant in the stroke situation
as it has been shown that in both the pre-stroke and post-stroke situation
blood viscosity is increased. For that reason a rehabilitation programme
based upon exercise alone is not in the best interests of the post-stroke
patient.
In addition to regular physical activity, post-stroke patients would
benefit from dietary changes with a reduced intake of meat and fats and an
increase in the intake of oily fish.
Competing interests:
None declared
Competing interests: No competing interests
I applaud the attempts of Boysen et al to improve patients ability to
exercise after stroke [1]. The article however, together with the
accompanying editorial [2] appeared to look upon exercise as an end in
itself – and this may be attractive in terms of the secondary prevention
of cerebrovascular disease. From a rehabilitation perspective however, uni
-model methods of rehabilitation after complex neurological injuries
appear anachronistic.
Management of stroke begins with the acute management and ends when
the individual is able to ‘participate fully’ in the community, or as
fully as the residual ‘impairment’ allows (using the terminology of the
WHO [3]). There is general agreement in the UK that there needs to be a
smooth path linking inpatient rehabilitation with community-based
rehabilitation, both of which will be multiprofessional. One of the
failings of community-based rehabilitation in the UK, however, is that it
tends to be discontinued when walking indoors and the basic activities of
daily living are seen to have been safely achieved, with assistance if
needed. This often precludes the ability to participate fully in the
community.
Late stage community rehabilitation is often lacking but, when
present, attempts to overcome the post-stroke loss of confidence, chronic
fatigue and depression partly through increasing ‘participation’ in the
community. This involves facilitating the use of public transport –
enabling individuals to get on/off buses and trains, drive cars etc. For
those stroke survivors who were working at the time of their stroke, the
techniques of vocational rehabilitation [4] may facilitate returning to
work. If exercise is seen to result in purposeful activities, compliance
may improve? What is the point of exercise classes at council-run leisure
centres [2] if potential participants cannot reach them? Most people in
this situation prefer to travel independently, thus avoiding the
frustrations of community-based transport.
For those unable to walk at the conclusion of physiotherapy,
consideration should be given to the use of electric powered wheelchairs
for those who fulfil the exacting criteria currently in use [5]. It
appears that powered wheelchairs, which can be very effective for some
older individuals [6], are infrequently utilised by some PCTs (Frank AO
unpublished data).
Exercise needs to be seen in perspective – as part of a co-ordinated
community-based rehabilitation programme for those whose post-stroke
impairment requires it.
Reference List
(1) Boysen G, et al and 11 more. ExStroke pilot Trial of the effect
of repeated instructions to improve physical activity after ischaemic
stroke: a multinational randomised controlled trial. BMJ 2009; 339(1st
August):273-276.
(2) Mead G. Exercise after stroke. BMJ 2009; 339(1 August):247-248.
(3) World Health Organization: report by the secretariat. The
International Classification of functioning, disability and health (ICIDH-
2). Geneva: World Health Organisation, 2001
(4) Frank AO, Thurgood J. Vocational rehabilitation in the UK:
opportunities for health-care professionals. Int J Ther Rehabil 2006;
13(3):126-134.
(5) Frank AO, Ward JH, Orwell NJ, McCullagh C, Belcher M.
Introduction of the new NHS Electric Powered Indoor/outdoor Chair (EPIOC)
service: benefits, risks and implications for prescribers. Clin Rehabil
2000; 14(December):665-673.
(6) Evans S, Frank A, Neophytou C, De Souza LH. Older adults' use
of, and satisfaction with, electric powered indoor /outdoor wheelchairs.
Age and ageing 2007; 36(4):431-435.
Competing interests:
Andrew Frank is Senior Independent Clinical Adviser to Kynixa Ltd, a rehabilitation company
Competing interests: No competing interests
Stroke Impact Scale
Re:PHQ 9
We use the proxy Stroke Impact Scale, and have found that it works
well when results from the 'big fixes' fall off, and progress can still be
found (if it exists) in terms of measurable psychological well-being -
which can combat the fear of diminishing retirns from exercise until the
'small steps' from exercise after stroke (with the patient guided to work
autonomously for neuroplastic change)start to become visible. Often in the
upper limb, this takes a long time of sustained effort and
training...which is where the SIS can help as adjunct to training records.
Competing interests:
None declared
Competing interests: No competing interests