Strength training after stroke: rationale, evidence and potential implementation barriers for physiotherapists.
What is muscle strength?
Muscle strength is defined as the ability to generate force against a load and is assessed as the maximum load that can be moved or the maximum torque that can be generated during a movement. Deficits in muscle strength are common in both the affected and unaffected side following stroke (Andrews and Bohannon 2000). Two other aspects of muscle strength which are effected after stroke are; 1) muscle endurance, the ability to generate torque against a load for an extended period of time and 2) muscle power, the ability to generate torque against a load at speed (Dawes et al 2005, Stavric and McNair 2012).
How does muscle strength relate to function after stroke?
Recent scientific literature demonstrates that deficits in muscle strength are one of the primary impairments which limit function following stroke, this is true for both lower and upper limb functions (Bohannon 2007, Bourbonnais and Vanden Noven 1989, Harris and Eng 2007, Harris et al 2001, Ng and Shepherd 2000). The relationship between muscle strength and function is strong (Dorsch et al 2012, Milot et al 2008, Ng and Hui-Chan 2012, Saunders et al 2008), to the extent that muscle strength can be used to predict walking speed (Nadeau et al 1999) and explains approximately 80% of variance in upper limb function (Harris and Eng 2007). Different functions place different demands on different muscles; for instance the strength of the dorsiflexor and hip flexor muscles strongly correlates with walking speed and endurance in people after stroke (Dorsch et al 2012), whilst the strength of the hip extensors, flexors and knee extensors are important for successful performance of stair climbing (Bohannon and Walsh 1991). This highlights the pivotal role of muscle strength to function following stroke.
What causes weakness after stroke?
Research in people with stroke reveals that there are neural and muscle structure and function changes following stroke which may to contribute to deficits in muscle strength. It is assumed that these changes reflect both primary impairments, directly caused by the stroke, and secondary changes due to immobility and physical inactivity.
The impact of neural changes following stroke on muscle strength is grossly quantified using voluntary activation. Voluntary activation refers to the extent to which the central nervous system is driving the muscle at the time of a muscle contraction. During a maximal voluntary contraction, voluntary activation in people without pathology is between 90 and 100%. A number of studies in people with stroke have identified marked deficits in voluntary activation, with voluntary activation of between 60-83% on the affected side and 6095% on the unaffected side (Harris et al 2001, Newham and Hsiao 2001, Riley and Bilodeau 2002, Signal et al 2008). Deficits in voluntary activation are likely caused by neural changes in the excitability of the cortical, subcortical and spinal contributions to muscle activation (Liepert 2003, Thickbroom et al 2004), along with alterations in motor unit recruitment (Frontera et al 1997, Gemperline et al 1995). These changes are presumed to reflect the neuronal damage caused by both the brain lesion and secondary disuse (Liepert 2003, Stulin et al 2003, Thickbroom et al 2004).
Alterations in muscle structure and function following stroke are evidenced by research demonstrating; muscle atrophy, fibre type alterations and muscle structure changes after stroke (Jorgensen and Jacobsen 2001, Metoki et al 2003, Sunnerhagen et al 1999). Whilst these peripheral changes are likely to contribute to a reduction in muscle strength, a recent study acknowledged that neural changes explained a much greater proportion of post-stroke weakness than muscle atrophy (Klein et al 2010).
Strength training after stroke
Strength training has been advocated for clinically stable stroke survivors for the past 15 years and most recently in the American Heart and Stroke Association's "Physical Activity and Exercise Recommendations for Stroke Survivors" (Billinger et al 2014) and in the New Zealand "Guidelines for the Management of Stroke" (Stroke Foundation of New Zealand and New Zealand Guidelines Group 2010). Strength training is exercise involving repeated muscle contractions against a load; the load is usually provided by the individual's body weight, elastic devices such as Theraband[R], free weights, machine weights or isokinetic systems such as the Biodex[R], with the aim of improving muscle strength, endurance and/or power (Saunders et al 2013).
The American Heart and Stroke Association recommend that strength training be conducted at 50-80% of the 1-repetition maximum (1-RM) for 10-15 repetitions for 2-3 days per week, and that resistance be increased as tolerance permits for people with stroke (Billinger et al 2014).
The evidence base for strength training includes a number of randomised controlled trials, many of which are small and not powered to detect a difference between the interventions under investigation (Flansbjer et al 2008a, Kim et al 2001, Lee et al 2008). There is also a larger body of cohort studies investigating strength training after stroke (Hill et al 2012, Ryan et al 2011). Additional evidence for the efficacy of strength training can be sourced from studies which combine strength training with other forms of training (Clark and Patten 2013, Jorgensen et al 2010, Sullivan et al 2007), such as cardiovascular endurance training or task specific training. Whilst the evidence base for strength training after stroke is growing, it is important to note that a recent meta-analysis investigating physical fitness training after stroke has indicated that there is still insufficient evidence to draw robust conclusions about the efficacy of strength training alone, as opposed to strength training combined with other forms of training, for gains in physical fitness, mobility or physical function (Saunders et al 2014).
Studies investigating the effects of strength training in people with stroke clearly demonstrate marked increases in muscle strength in response to training, with some studies describing gains from baseline in excess of 75% (Corti et al 2012, Hill et al 2012, Kim et al 2001, Lee 2010, Ryan et al 2011). Gains in strength appear to be specific to the muscle and action trained (Clark and Patten 2013, Engardt et al 1995, Lee 2010), although there is some evidence of carry over to the untrained side in response to unilateral training (Dragert and Zehr 2013, Hill et al 2012). The mechanism of these strength gains are likely to be mediated by both improvements in neural activation and muscle structure and function (Andersen et al 2011, Clark and Patten 2013, Ryan et al 2011). Studies which follow up participants to evaluate the retention of strength gains demonstrate the maintenance of gains for up to four years post-intervention (Flansbjer et al 2012, Severinsen et al 2014, Sullivan et al 2007), which is in contrast to cardiovascular training where gains tend to be lost when training is discontinued (Severinsen et al 2014).
The evidence for changes in functional ability in response to strength training is less clear, with some studies demonstrating significant gains in function (Bale and Strand 2008, Clark and Patten 2013, Duncan et al 1998, Teixeira-Salmela et al 1999, Yang et al 2006) while others are less convincing (Kim et al 2001, Lee 2010, Ouellette et al 2004, Severinsen et al 2014). Gains have been demonstrated in walking speed (Bale and Strand 2008, Duncan et al 1998, Engardt et al 1995, Lee et al 2008, Severinsen et al 2014, Sharp and Brouwer 1997, Yang et al 2006), endurance (Flansbjer et al 2008a, Hill et al 2012, Ouellette et al 2004, Yang et al 2006), sit to stand (Weiss et al 2000), stair climbing ability (Lee et al 2008, Teixeira-Salmela et al 1999) and upper limb function (Corti et al 2012, Patten et al 2013). Some of the disparity in the extent of gains seen in function may relate to the specificity of the strength training to the function being evaluated, the parameters of the training, and the population under investigation. A number of studies indicate that when training is conducted at a low intensity, short duration or with insufficient progression of load, gains in response to training are limited (Cooke et al 2010, Flansbjer et al 2008b, Kim et al 2001, Kluding et al 2011, Moreland et al 2003). It seems likely that adequate training parameters are necessary to drive a change in function.
However, the research evidence also suggests that strength training may be most effective when paired with task specific training (Andersen et al 2011, Clark and Patten 2013, Corti et al 2012, Cramp et al 2010, Jorgensen et al 2010, Patten et al 2013) or cardiovascular training (Andersen et al 2011, Jorgensen et al 2010, Lee et al 2008, Sullivan et al 2007). Combining strength training with task specific training may facilitate the transfer of strength gains to function. Recent work by Patten and colleagues comparing strength training combined with task specific training to task specific training alone in the upper limb have demonstrated superior results with the combined training (Corti et al 2012, Patten et al 2013). However, no studies comparing task specific training alone, strength training alone and combined strength and task training of the same dose and intensity have been undertaken to definitively answer the question of the best type or combination of interventions. It is also important to note there is a risk of over training if sufficient rest days are not provided with combined training (Sullivan et al 2007).
In addition to gains in strength and function, some studies investigating strength training after stroke have demonstrated gains at the participatory level and in health related quality of life (Chen and Rimmer 2011). More recent studies have also demonstrated a positive influence on other impairments such as cognitive function (Kluding et al 2011), depression (Sims et al 2009) and anxiety (Aidar et al 2012).
The uptake of strength training in clinical practice
Like many new interventions in stroke rehabilitation, such as task specific training, body weight supported treadmill training (BWSTT), constraint induced movement therapy (CIMT) and cardiovascular training, it is reasonable to expect that there may be a delay in the integration of the intervention into standard clinical practice as the research body grows and findings are disseminated to clinicians (Bayley et al 2012). Comparable with task specific training, strength training has the potential to be delivered within current resources and healthcare frameworks, therefore uptake might be expected to be faster than in interventions such as CIMT and BWSTT which require specialist equipment or changes to the healthcare framework to facilitate delivery. Yet the evidence from audit, observational and documentation studies suggests that strength training has not been well integrated into clinical practice. A number of studies in the United States, New Zealand and Europe have sought to document and categorise the scope of physiotherapy intervention for people following stroke. Whilst there appear to be regional differences in the content of therapy, often these studies do not overtly characterise strength training as part of their taxonomy of therapeutic interventions or they subsume strength training with interventions such as passive movement and selective motor control (De Wit et al 2006, DeJong et al 2004, Gassaway et al 2005, McNaughton et al 2005). A recent New Zealand study found only 58% alignment with the New Zealand Clinical Guidelines for Stroke Management 2010 recommendations for the management of muscle weakness which includes using strength training (Johnston et al 2013). In general, these studies suggest that strength training is not a core part of many physiotherapists' clinical practice.
It is also important to note that the actual average physiotherapy intervention in inpatient rehabilitation is between 35 minutes and an hour per working day (Bernhardt et al 2007, Bernhardt et al 2008, Gassaway et al 2005); with New Zealand studies indicating that in our country, people with stroke are at the lower end of this estimate (McNaughton et al 2005, Thompson and McKinstry 2009) and observational studies highlight that much of the patients' time in physiotherapy is spent inactive and working at very low intensities (Kaur et al 2012, MacKay-Lyons and Makrides 2002, West and Bernhardt 2012). Collectively this research suggests that strength training has not been well integrated into current clinical practice, and that when it has, it is likely to be being carried out at a dose and intensity of training which does not meet recommended guidelines.
What limits physiotherapists' uptake of strength training?
That strength training has not been taken up into clinical practice prompts the question; Why? Research investigating the barriers to implementing research and evidence based practice guidelines into clinical practice identifies potential systemic, team and individual barriers to implementation in stroke rehabilitation (Bayley et al 2012, McCluskey et al 2013). This clinical commentary focuses on the individual barriers to the implementation of strength training in people with stroke for physiotherapists and draws on both research evidence and our experience implementing moderate to high intensity strength training for people with stroke at AUT University (Signal et al 2014).
One frequently cited barrier to implementing evidence based practice guidelines is patient tolerance to the recommended intervention (Bayley et al 2012). Recommendations for the implementation of strength training advise that people with stroke work at an intensity of 50-80% of their 1-RM. This represents a moderate to high intensity of effort; the person should only be able to complete 8 to 14 repetitions of an exercise before they experience volitional fatigue. In order to exercise at this intensity it is necessary to work very hard; people with stroke will be sweating, concentrating fully on the exercise and at the last repetition of a set they should be unable to complete another repetition. This may be a level of exercise that many physiotherapists are unused to using with their patients and may raise concerns for the physiotherapist. However it is worth noting that many research studies and our own experience indicate that provided adequate familiarisation and initiation of training at the low end of recommended training parameters is undertaken, it is feasible to utilise strength training with people who; have severe physical disability following stroke, are older (85+ years) and have co-morbidities (Hill et al 2012, Jorgensen et al 2010, Signal et al 2014).
To apply strength training using the recommended training parameters, physiotherapists must be able to evaluate 1-RM and repetition maximum (RM) based exercise sets. Given that exercise based rehabilitation has only recently been overtly incorporated into undergraduate physiotherapy curriculums, many physiotherapists may not possess this knowledge. Research evidence and best practice guidelines provide little guidance in the pragmatics of intervention delivery (Bayley et al 2012, McCluskey et al 2013, Salbach et al 2007); most strength training guidelines do not describe how to establish 1-RM or RM sets, nor do they provide examples of specific exercises or exercise progressions and modifications for people with stroke (Billinger et al 2014, Mead and Van Wijck 2013), making implementation challenging. Physiotherapists are often more familiar with utilising body weight and alterations such as change in step or seat height to alter training intensity. However, body weight exercises do not lend themselves well to progressive overload and it is often difficult for the therapist to gauge and graduate the intensity of the exercise. Machine and free weights enable the therapist to more readily establish the 1-RM or specified RM of an exercise to ensure that strength training is at the appropriate intensity. In order to gain the practical knowledge to effectively deliver strength training in people with stroke some physiotherapists may need to seek advice from other clinicians experienced in strength training or attend post-graduate training in exercise rehabilitation.
Historically strength training was discouraged in people with neurological conditions for fear that it would exacerbate hypertonia and compensatory movement patterns (Bobath 1990), these concerns may still prevail today. Compensatory movements are thought to enable task performance but be potentially detrimental to long term recovery of function (Levin et al 2009). Early studies investigated whether strength training increased hypertonia in people with stroke and clearly demonstrated that it does not (Flansbjer et al 2008a, Sharp and Brouwer 1997, Teixeira-Salmela et al 1999). Furthermore, a recent study has shown that the Bobath approach does not result in more normal movement patterns than task specific training (Langhammer and Stanghelle 2011) and an additional study has demonstrated that when strength training and task specific training are combined, they result in a more normal movement pattern for reaching and grasping than task specific training alone (Corti et al 2012). These findings indicate that appropriately applied strength training will not increase hypertonia and is more likely to improve movement patterns, rather than reinforce compensatory movement patterns in people with stroke. The challenge for clinicians is to identify suitable strength training exercises and to utilise techniques to stabilise the patient and maintain normal movement patterns during exercise.
It is also worth noting that for most neurological physiotherapists, the construct of neural plasticity underpins their clinical practice. Much of the evidence from neural plasticity literature has highlighted the importance of dose of training to achieve gains in people with stroke (Kwakkel et al 2004), meaning that the focus is often on increasing the number of repetitions of an exercise. However, recently the importance of intensity of training has been emphasised (Bowden et al 2013).This is a key issue in relation to strength training as research in healthy people indicates that strength gains can be achieved with as little as one set, provided the intensity is sufficient (Garber et al 2011). The maintenance of intensity in strength training requires regular re-assessment of the 1-RM or RM to ensure that the intensity of training is maintained and progressed as the person gains strength.
It has previously been suggested that physiotherapists are overly precautionary in their rehabilitation of people with stroke for fear of adverse events and negative symptoms (Brazzelli et al 2011, Rose et al 2011). Few studies report adverse events in response to strength training in a detailed manner (Hill et al 2012, Lee et al 2008, Ouellette et al 2004, Stuart et al 2009, Sullivan et al 2007). No fatal adverse events have been reported in the literature and strength training in people with stroke is considered a safe and relatively low risk intervention (Billinger et al 2014). To minimise any risks, pre-exercise evaluation should include medical practitioner clearance, a complete medical history and assessment to identify absolute and relative contraindications to exercise, and the patients' functional level and motor, sensory, cognitive and perceptual impairments (Dennis et al 2012).
As reporting of adverse events is limited, there is little information to guide therapists in relation to normal and abnormal responses to strength training in people with stroke. Our clinical experience indicates that people with stroke can experience symptoms such as dizziness and pain in response to strength training (Signal et al 2014). Whilst generally not of the severity to be deemed an adverse event or require termination of the intervention, these symptoms have the potential to impact the patients' engagement with rehabilitation if not carefully managed and may require modification of the exercise or training parameters.
Although strength training interventions may result in a medium and long term decrease in cardiovascular risk factors (Mead and Van Wijck 2013), the immediate effect of strength training is cardiovascular stress which results in an increase in both diastolic and systolic blood pressure. The magnitude of this cardiovascular stress is a function of the percentage of 1-RM, the muscle mass being worked, the duration of the contraction and rest periods, and whether the person's attempts to utilise a Valsalva manoeuvre during the exercise (Lamotte et al 2010, Sorace et al 2012). Hence a therapist who is concerned about the cardiovascular stress on a patient may monitor heart rate and blood pressure prior to the training session to ensure that these parameters are within safe levels to begin exercise, begin training at a lower intensity, increase the speed and therefore reduce the duration of contractions, utilise rest periods of at least 90 seconds, utilise unilateral contractions, modify exercises as required to accommodate postural hypotension and encourage the person to focus on breathing during exercise (Dennis et al 2012, Sorace et al 2012).
The development of musculoskeletal pain in response to strength training may result from excessive loading of a joint or poor biomechanics during exercise. People with stroke appear to be more at risk of developing pain when they have a pre-existing musculoskeletal condition. Osteoarthritis (OA) is common in middle aged and older adults and is a frequent co-morbidity seen in people with stroke (Juhl et al 2014). Strength training is strongly recommended in guidelines for the management of OA and the recommended training parameters are similar to those recommended for people with stroke (Larmer et al 2014). Therefore, the progression of exercises in people who have stroke and musculoskeletal pain should be symptom limited, where exercises are progressed only when there is no increase from baseline pain in response to the intervention. Attention to exercise selection and order to ensure sufficient rest of muscle groups, and consideration of the maintenance of normal movement patterns during exercise is also important.
The research evidence indicates that strength training increases strength and has potential to improve function in people with stroke. Despite being strongly advocated in best practice guidelines; strength training at the recommended training parameters does not appear to have been well integrated into clinical practice. This commentary has focused on the potential barriers that physiotherapists may perceive and experience to the implementation of strength training in their clinical practice. Research and clinical experience indicate that strength training is safe and well tolerated in most patients with stroke, however a thorough assessment of patient risk, monitoring for negative symptoms and for some patients, modification of exercises and training parameters, may be required. Some physiotherapists may wish to seek new knowledge and practical skills in order to effectively apply strength training within the recommended training parameters for people with stroke. The research evidence, strength training guidelines and clinical experience indicate that strength training for people with stroke should be carried out;
After a thorough evaluation of the patient which identifies absolute and relative contraindications to exercise and the patients functional limitations and impairments. With specificity; where the muscles exercised, their type, range and speed of action relate to the individual's functional limitations. Combined with other forms of training such as task specific training. Following a familiarisation period, with the intensity of training progressively maintained or increased as the patient gains strength. Whilst monitoring for negative symptoms and modifying the training parameters as required. Using stabilising, cueing and supporting techniques to ensure the maintenance of a normal movement pattern during exercise. At an intensity and dose sufficient to ensure training overload.
* Deficits in muscle strength are common after stroke and are strongly related to function.
* Strength training increases strength and has potential to improve function in people with stroke.
* Strength training at the recommended training parameters does not appear to have been well integrated into clinical practice.
* Barriers to the implementation of strength training in clinical practice may in part be addressed by new knowledge and practical skills.
I would like to acknowledge my colleagues at AUT University and the participants with stroke who have supported my doctoral studies. In particular, I would like to acknowledge Nicola Saywell and Dr Denise Taylor for their contributions to this work.
Nada Signal's doctoral studies were supported by a Health Research Council Disability Placement Scholarship and a STAR Grant from the Tertiary Education Commission.
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Nada EJ Signal MHSc (Rehab), BHSc (Physio)
Lecturer and Senior Research Officer
Health and Rehabilitation Research Institute, Department of Physiotherapy AUT University
ADDRESS FOR CORRESPONDENCE
Nada EJ Signal, Lecturer and Senior Research Officer, Health and Rehabilitation Research Institute, Department of Physiotherapy, AUT University, Private Bag 92006, Auckland, New Zealand. Phone: +64 9 921 9999. Email: firstname.lastname@example.org
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|Title Annotation:||INVITED CLINICAL COMMENTARY|
|Author:||Signal, Nada E.J.|
|Publication:||New Zealand Journal of Physiotherapy|
|Date:||Jul 1, 2014|
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