Combined Aerobic and Resistance Training for Cardiorespiratory Fitness, Muscle Strength, and Walking Capacity after Stroke: A Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.104498Get rights and content

Abstract

Background

Cardiorespiratory fitness, measured as peak oxygen consumption, is a potent predictor of stroke risk. Muscle weakness is the most prominent impairment after stroke and is directly associated with reduced walking capacity. There is a lack of recommendations for optimal combined aerobic training and resistance training for those patients. The purpose of this study was to systematically review and quantify the effects of exercise training on cardiorespiratory fitness, muscle strength, and walking capacity after stroke.

Methods

Five electronic databases were searched (until May 2019) for studies that met the following criteria: (1) adult humans with a history of stroke who ambulate independently; (2) structured exercise intervention based on combined aerobic training and resistance training; and (3) measured cardiorespiratory fitness, muscle strength, and/or walking capacity.

Results

Eighteen studies (602 participants, average age 62 years) met the inclusion criteria. Exercise training significantly improved all 3 outcomes. In subgroup analyses for cardiorespiratory fitness, longer training duration was significantly associated with larger effect size. Likewise, for muscle strength, moderate weekly frequency and lower training volume were significantly associated with larger effect size. Furthermore, in walking capacity, moderate weekly frequency and longer training duration were significantly associated with larger effect size.

Conclusions

These results suggest that an exercise program consisting of moderate-intensity, 3 days per week, for 20 weeks should be considered for greater effect on cardiorespiratory fitness, muscle strength, and walking capacity in stroke patients.

Introduction

Cardiorespiratory fitness (CRF) is one the strongest predictors of stroke risk. Measured as peak oxygen consumption (VO2peak), CRF was inversely associated with a 2.30-fold risk for any type of stroke.1 Compared to age-matched sedentary groups, individuals with stroke have about 50% decreased CFR2 and are at the risk of cardiovascular events by over 25%.3 Muscle weakness is the most prominent impairment after stroke,4 directly associated with reduced walking speed and endurance.5 Hemiparesis, affecting 65% of stroke victims 3, can double physiological energy for normal walking, compared to that of healthy persons.6 In this regard, exercise training (ET) or physical activity is required for the rehabilitation of stroke populations.

Physical activity is defined as any bodily movement produced by skeletal muscle that substantially increases energy expenditure.7 Exercise is a subset of physical activity that is planned, structured, and repetitive and is performed deliberately for the purpose of improving or maintain physical fitness.8 The participation of physical activity should be fundamentally encouraged because low levels of physical inactivity is predominant in stroke survivors, which increases cardiovascular risk.9 In particular, well-designed exercise programs are necessary to facilitate their participation in physical activity and more effectively improve CFR, muscle strength, and walking capacity as mentioned above.

A recent meta-analysis study found that high-intensity aerobic training (AT) increases VO2peak further than AT with low-intensity, but walking capacity, measured as walking speed or distance, is not improved in ambulatory persons with stroke.10 Another meta-analysis showed that resistance training (RT) increases muscle strength but not walking distance, measured using the 6 minutes walking test (6MWT).11 Meanwhile, regarding non-ambulatory stroke survivors, one meta-analysis found that ET increases both VO2peak and walking distance.12 However, these previous meta-analyses only included a small number of studies and did not provide appropriate exercise guidelines.

Although both AT and RT are essential for stroke patients, no meta-analysis has investigated the effects of combined AT and RT on the key elements of physical fitness: CFR, muscle strength, and walking capacity. Billinger et al.7 provided comprehensive physical activity and exercise recommendation for stroke survivors based on systematic literature reviews. However, structured exercise intervention with detailed demographic and training factors are needed to be statistically reviewed by a meta-analysis combining results from comparable studies which enhance the validity and reliability of conclusions. For the improvement in all 3 factors, CFR, muscle strength, walking capacity, combined AT and RT is ideal compared to any singular exercise modality. Therefore, the primary purpose of this study was to evaluate the effects of combined AT and RT on CFR, muscle strength, and walking capacity in ambulatory persons with stroke by conducting a systematic review and meta-analysis. This review carefully examined the specific variables of the ET regimens (i.e., intensity, duration, frequency, and volume), identified different types of stroke populations (i.e., age, gender, body mass index (BMI), stroke type, and post-stroke period), and reported adverse events to provide sufficient evidence for establishing optimal exercise guidelines. Moreover, this study also attempted to reveal current issues in this field and inspire future research to resolve health issues associated with stroke.

Section snippets

Materials and Methods

This current systematic review followed the strategy of the PRISMA statement.13 Ethics committee approval was not sought for the present study because this meta-analysis study was based on the results of previously published studies.

Study Selection and Characteristics

The search resulted in 2817 potential studies (Fig 1). From the titles and abstracts, 2742 studies were excluded based on the inclusion criteria, and then 75 full text studies were reviewed. Of these, 18 articles met the criteria. In selected studies, 3 AT groups18,19 and one Chinese martial art group20 were excluded from this analysis. One CON conducting combined AT and RT21 was included in exercise group (EX). Consequently, nineteen ET cohorts in eighteen studies were selected.

Participants

Table 1 shows

Discussion

The primary results of this meta-analysis study were that ET significantly increased CRF, muscle strength, and walking capacity by 12%, 32%, and 14%, respectively, in ambulatory persons with stroke of an average age of 61.2 years. Moderate heterogeneity was found between studies on muscle strength and walking capacity except for CFR. In subgroup analyses for CFR, longer training duration was significantly associated with larger ES. For muscle strength, moderate weekly frequency and lower

Summary and Conclusion

This systemic review and meta-analysis found that ET significantly improved all CRF, muscle strength, and walking capacity in ambulatory persons with stroke. Through subgroup analyses, this study suggests that moderate-intensity (AT: 40%-60% of HRR, RT: 50%-70% of 1RM) and 3 days per week for 20 weeks should be considered as a priority in ET program for greater effect on all 3 outcomes. For detailed training variables, a volume of 30 minutes (AT), 2 sets of 10-12 repetitions, and 8 exercises

Authors' Contributions

Junghoon Lee: Study design, data collection, data analysis, data interpretation, manuscript writing; Audrey J Stone: Manuscript writing, manuscript review.

Ethics Approval and Consent to Participate

Not applicable

Consent for Publication

Not applicable

Availability of Data and Material

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Acknowledgments

We would like to thank the authors from the included studies who provided additional information.

Conflict of Interest

The authors declare that they have no conflict of interest.

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    Financial Disclosure: There is no received funding for this study.

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