Determining Safe Participation in Aerobic Exercise Early After Stroke Through a Graded Submaximal Exercise Test

Abstract

Objective The benefits of aerobic exercise early after stroke are well known, but concerns about cardiovascular risk are a barrier to clinical implementation. Symptom-limited exercise testing with electrocardiography (ECG) is recommended but not always feasible. The purpose of this study was to determine the frequency of and corresponding exercise intensities at which ECG abnormalities occurred during submaximal exercise testing, that would limit safe exercise prescription beyond those intensities. Methods This study was a retrospective analysis of ECGs from 195 patients who completed submaximal exercise testing during stroke rehabilitation. A graded submaximal exercise test was conducted with 5- or 12-lead ECG and was terminated on the basis of predetermined endpoint criteria (heart rate, perceived exertion, signs, or symptoms). ECGs were retrospectively reviewed for exercise-induced abnormalities and their associated heart rates. Results The peak heart rate achieved was 65.4% (SD = 10.5%) of the predicted maximumheart rate or 29.1% (SD = 15.5%) of the heart rate reserve (adjusted for beta-blocker medicationsThe test was terminated more often because of perceived exertion (93/195) than because of heart rate limits (60/195). Four patients (2.1%) exhibited exercise-induced horizontal or downsloping ST segment depression of ≥1 mm. Except for 1 patient, the heart rate at test termination was comparable to the heart rate associated with the onset of the ECG abnormality. Conclusion A graded submaximal exercise test without ECG but with symptom monitoring and conservative heart rate and perceived exertion endpoints may facilitate safe exercise intensities early after stroke. Symptom-limited exercise testing with ECG is still recommended when progressing to higher-intensity exercise. Impact Concerns about cardiovascular risk are a barrier to physical therapists implementing aerobic exercise in stroke rehabilitation. This study showed that, in the absence of access to exercise testing with ECG, submaximal testing with conservative heart rate and perceived exertion endpoints and symptom monitoring can support physical therapists in the safe prescription of aerobic exercise early after stroke.

Adverse Events During Submaximal Aerobic Exercise Testing in People With Subacute Stroke: A Scoping Review

“…We also determined, within in each study, the percentage of participants experiencing SAEs and non-SAEs. Adverse events were classified as serious if they led to permanent change in function or resulting in disability, a life-threatening event (eg, stroke, myocardial infarction, cardiopulmonary arrest) or death, 31 or were defined as serious by the authors.…”

“…Studies were conducted in Australia (46%), [41][42][43][44][45][46] United Kingdom (15%), 47,48 United States (15%), 49,50 Canada (8%), 31 Japan (8%), 51 and Switzerland (8%). 52 Study designs 38 included cross-sectional studies (46%), 31,43,45,48,51,52 randomized controlled trials (31%), 41,44,46,47 cohort studies (15%), 49,50 and nonrandomized intervention studies (8%). 42 Sample size ranged from 3 to 195, with 92% of the studies having 40 participants or less.…”

“…30 Maximal tests, on the other hand, require individuals to exercise to voluntary exhaustion, 30 which may be difficult to achieve due to functional impairments poststroke. 31 There is limited guidance for how to safely conduct submaximal AEx testing for individuals with stroke and comorbidity. 4,13,14 Reviews on the safety of maximal and submaximal AEx testing for individuals with stroke provide limited details of the protocols (eg, warm-up time, stage time, resistance, monitoring).…”

Exercise-Based Stroke Rehabilitation: Clinical Considerations Following the COVID-19 Pandemic

“…Therefore, cardiorespiratory responses, including heart rate and rhythm, blood pressure, oxygen saturation, oxygen uptake, and ratings of perceived exertion and dyspnea scales 84 should be monitored continuously throughout the exercise stress test for individuals with previous COVID-19 infection who experienced moderate to severe or post-acute symptoms (Figure 2). Other submaximal exercise stress testing protocols without ECG or gas exchange are clinically feasible, 85 valid and reliable alternatives to maximal exercise stress testing 86 and may be most appropriate for mild cases without significant comorbidities and if exercise rehabilitation programs target only low to moderate intensity. 14 Nonetheless, in accordance with current stroke exercise recommendations 14,15 clinicians are required to objectively monitor (1) heart rate via heart rate monitor or manual palpation, (2) blood pressure via manual sphygmomanometer or automated blood pressure monitoring, (3) oxygen saturation via pulse oximeter, (4) ratings of perceived exertion, and (5) dyspnea scale throughout the test, with values being recorded during last 30 seconds of each stage of exercise.…”

“…Therefore, cardiorespiratory responses, including heart rate and rhythm, blood pressure, oxygen saturation, oxygen uptake, and ratings of perceived exertion and dyspnea scales 84 should be monitored continuously throughout the exercise stress test for individuals with previous COVID-19 infection who experienced moderate to severe or post-acute symptoms ( Figure 2 ). Other submaximal exercise stress testing protocols without ECG or gas exchange are clinically feasible, 85 valid and reliable alternatives to maximal exercise stress testing 86 and may be most appropriate for mild cases without significant comorbidities and if exercise rehabilitation programs target only low to moderate intensity. 14 …”