1.1 Introduction
The occurrence of stroke has increased immensely in recent times, particularly in developed nations. Statistics show that in the next few decades, the number of stroke patients shall rise due to demographic changes (increase in the aged population) and other health factors such as increase in obesity and diabetes levels caused by a rise in people leading a sedentary lifestyle (Hu, Satija and Manson, 2015; World Bank, 2016). In their study, Christos et al. (2014) put these statistics in perspective where they found that the global obesity and diabetes prevalence has risen as one in every five persons (20%) is at a high risk of developing diabetes, 12.5% of the of the world population are pre-diabetic (have diabetes signs), more than 50% of the adult population are obese (have BMIs higher than 30) and more than 76% of the adult population are overweight (have a BMI of above 25). Further, studies show that physical activity is one of the most effective means of preventing and rehabilitating diabetes, obesity and stroke patients (DeFina et al., 2015; Ekblom-Bak et al., 2014; Li and Siegrist, 2012.). Therefore, as the number of persons diagnosed with stroke and other cardiovascular diseases increase, so will the demand for the services of physiotherapists.
This research examines the practice and perception of physiotherapists who conduct cardiovascular rehabilitation on stroke patients in Ireland, using data gathered through qualitative research. Chapter 1 sets the context for the discussion, reviewing a range of international sources on stroke and cardiovascular rehabilitation. Chapter 2 presents the research methodology, outlining details of the qualitative research methods used while Chapter 3 presents the results and discusses them in detail. Finally, Chapter 4 outlines the final conclusions and makes recommendations.
1.2 Aim
This study aims at highlighting the benefits of cardiovascular rehabilitation of stroke patients and assess current attitudes of Irish physiotherapists on cardiovascular rehabilitation of stroke patients through qualitative study of a sample of physiotherapists in Ireland.
1.3 Literature Review
This section presents a review of sources relating to stroke and to cardiovascular rehabilitation of stroke patients, drawing on secondary research of a number of books, journals, and online sources. The review of the literature demonstrates links between stroke and cardiovascular disease, and highlights why cardiovascular rehabilitation is vital to well-being and longevity of stroke patients. It can be used safely for even those with moderate-severe impairment and is more effective the sooner it is initiated after stroke. As is also highlighted by this review, however, cardiovascular rehabilitation is often omitted from stroke rehabilitation of patients in Ireland despite evidence of the effectiveness of this approach.
Pathophysiology and Aetiology
Stroke is categorised as a ‘cardiovascular disease’, which is defined as a condition that involves disruption to circulatory system function (Perk et al., 2012). On a cellular level, stroke ‘affects mechanisms of haematosis and perturbs interactions between circulating blood elements, the blood vessel itself, and brain parenchyma (Hermitte et al., 2013). On a functional level, stroke affects the regulation of hemodynamic and metabolism (Amin-Hanjani et al., 2016). Mohr et al. (1978) further added that ischemia represents about 80% of strokes, about half of these are thrombotic events. Ischemic stroke most often occurs due to a lack of blood flow to all or part of the brain due to blockage of a blood vessel, leading to neurons being deprived of vital glucose and oxygen. The effects are rapid, as the brain cannot store glucose (Shah,2009, p.2). The deprivation of the brain’s necessary substrates, ‘if severe and prolonged, results in the interruption of normal cellular processes and eventual cell death with breakdown of the neuronal cell membrane’ (McElveen and Always, 2009, p.9). Non-traumatic intracerebral haemorrhage causes 10-15% of strokes, originating from deep penetrating vessels and causing localised pressure injury in the brain by disrupting connecting pathways, leading to intracerebral or subarachnoid haemorrhage (Shah,2009, p.2). If symptoms last less than a couple of hours, the condition is known as a transient ischemic attack or mini-stroke. Ischemic stroke generally presents with sudden onset of neurological dysfunction, this may involve symptoms such as weakness, numbness, loss of vision, diplopia, dysarthria, gait disorder, aphasia, feelings of disturbed consciousness, and light-headedness, while headache may be a sign but it more commonly a symptom of haemorrhagic stroke (McElveen and Alway, 2009,pp.11-12).
Patients with other cardiovascular diseases are at greater risk of stroke (Gordon et al., 2004). Atherosclerotic disease of the carotid artery, the major artery supplying blood to the brain, is estimated as being responsible for 20-30% of all strokes (Wakhloo et al., 2004). Atherosclerosis can be caused or worsened by cholesterol level in the blood, diabetes, smoking or persistent high blood pressure (Scannapieco et al., 2003). Progression of atherosclerosis can be linked to various factors including dysfunction of smooth muscle cell activation, disruptions in platelet activation, and proliferation and inflammation (Libby, Ridker and Maseri, 2002). In the later stages of the disease thrombotic cardio- or cerebrovascular events can occur when blood flow in the heart or brain is interrupted by plaque formation (Chrissobolis and Sobey, 2016, pp.3-9).
Other cardiovascular conditions such as cardiac arrhythmias can also lead to stroke, for example atrial fibrillation may lead to embolic stroke due to clots lodging themselves in an artery, while haemorrhagic strokes may be caused by cerebrovascular hypertension as well as defects in the blood vessels such as aneurysm, AVM, or result from taking blood-thinning medications (Chrissobolis and Sobey, 2016, pp.3-9). Stroke survivors with pre-existing cardiovascular disease are at greater risk for exertion-related cardiac complications because physical activity places greater demands on the cardiovascular system of hemiplegic patients than on that of healthy adults (Gordon, 2004).
Epidemiology
The occurrence of stroke has increased immensely over the years especially in developed nations. In 2012, the World Health Organisation (WHO) reported stroke or cerebrovascular accident as the second leading cause of death globally (WHO, 2014). In Ireland, stroke was estimated to be the third leading cause of death and the leading cause of long-term adult disability in 2008 (Irish Heart Foundation, 2008, p.6).Dyken et al. (1984) further added that since stroke is age-related, the risk of suffering from stroke doubles for each decade after 55 years.
Stroke tends to be more common in men than women within the age range of between 45 and 84 years (Tuomilehto, 2014, p.109), though the Framingham Heart Study shown that the incidence of stroke in men has declined to be only slightly higher than women in the period 1990-2004 (Seshadri and Wolf, 2016, p.231). Recent data from the National Stroke Audit shows that of approximately 874 cases of stroke, females had a mean age of 77 as compared to men whose mean age was 71 years (Irish Heart Foundation, 2015, p.60).The age-related risk of stroke, combined with the growing population of persons aged above 50 in the Western world, suggests risk of stroke in the population will increase (Mayo et al., 1999).
Modifiable risk factors of stroke include age, sex, weight, ethnicity, and genetic factors. Hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation, cardiovascular disease, alcohol abuse, diabetes, hyperlipidaemia, asymptomatic carotid stenosis, poor diet, obesity, and central body fat distribution are other modifiable factors (O’Donnell, 2010; Tuomilehto, 2014, pp.108-109). Physical inactivity is also a modifiable risk factor (Sacco 2001; O’Donnell et al., 2010), and a higher measure of cardiorespiratory fitness was associated with lower risk of stroke in men by one study that examined 2,011 middle-aged men over 11 years(Kurl еt al., 2003). Stamler еt al. (1999) found that a low-risk lifestyle (cholesterol<200mg/dl, blood pressure<120/80mmHg, not smoking) could be associated with 52-76% lower risk of stroke mortality.
A study by Kelly et al.(2012) in North Dublin found higher incidence of stroke in this region than in nine other high-income populations. This was considered due to risk factors such as high rates of smoking and atrial fibrillation. Lee et al.’s analysis of 18 cohort studies overall indicated that those with a higher level of cardiorespiratory fitness were less likely to have a stroke, those considered moderately active were 17% less likely and those considered highly active were considered 25% less likely to have a stroke or die of stroke (Lee et al., 2003).
When compared to those who had low levels of activity, people with moderate levels of activity were 9% less likely to get ischemic stroke and 15% less likely to suffer from haemorrhagic stroke. Those who had high activity levels reduced their risk even further as they were 21%less likely to get ischemic stroke and 34% less likely to suffer from haemorrhagic stroke (Lee et al., 2003). A recent study by Pandey et al. (2016) that examined data for 19,815 middle-aged individuals also showed that low cardio respiratory fitness is strongly associated with stroke.
Further, the study found that higher midlife cardio respiratory fitness was associated with lower risk of stroke hospitalisation, even in those who already had stroke risk factors such as diabetes mellitus, hypertension, and atrial fibrillation (Pandey et al., 2016).Therefore, cardio respiratory fitness is essential to stroke prevention. According to the authors, ‘Regular exercise has previously been associated with reduction in blood pressure, decreased insulin resistance, and lower heart rates. Our study findings highlight the role of regular exercise and higher CRF in midlife as a potential stroke prevention strategy. This protective effect of higher CRF seems to go beyond risk factors modification (Pandey et al., 2016).
Earlier stroke and increased severity of stroke has been associated with obesity in a Danish population (Dehlendorff et al., 2014). Analysis of 13,549 participants as part of a study by Yatsuya et al.(2010) showed that the risk for participants in the higher body mass index (BMI) category was 1.4 to 2.1 times higher than for those in thelowest BMI category, with some small variations according to sex and ethnicity. With Ireland set to become Europe’s most obese country according to findings by WHO (Irish Times, 2015) it can only be expected that stroke tendency will rise.
The increasing number of diabetic people and those leading a sedentary lifestyle will also likely lead to increased stroke tendency. Data from the National Stroke Audit (2015) show that there has been a major increase in the incidence of stroke among persons under the age of 65, out of which 24% of the approximated 874 cases occurred to persons under the age of 65 in 2014 as compared to 19% in 2008 (Irish Heart Foundation 2015, p.60). Stroke survivors are also at risk of a recurrent event, risk ranging from 20-30% within the first five years following (Kaplan et al., 2005). Those who have had a transient ischemic attack have a high risk of stroke in the next two weeks.
Dimyan and Cohen (2011, p.76) also noted that approximately one-third of patients with stroke exhibit persistent disability after the initial cerebrovascular episode, with motor impairments accounting for most post stroke disability. Post-stroke problems relate to the ‘body structure and function dimension’ and in the ‘activity and participation dimension’ (WHO, 2001). Body structure and function effects (known as “impairments”), such as hemiplegia, spasticity, and aphasia, are the main neurological disorders caused by stroke (Durstine et al., 2008, p.249).It was estimated that 14% of stroke survivors achieve a full recovery in physical function, but between 25% and 50% require assistance in daily living, and half experience severe long-term effects such as partial paralysis (Gordon et al., 2004).
Gordon et al. (2004) further added that the reduced ability to perform daily functions can result from the level of body impairment but also from factors such as low mood, adaptability and coping skills, cognition and learning abilities, comorbidities, physical endurance levels, and the amount and type of rehabilitation training. Post-stroke cognitive impairment is perceived as resulting from neuro anatomical lesions on areas such as the hippocampus and cerebral micro-bleeds among numerous and interrelated factors (Sun et al., 2014).The Maastricht CODAS in the Netherlands which examined the cognitive function of 176 participants within the first year of their first stroke suggested that cognitive impairment occurs in up to 70% of stroke victims (Sun et al., 2014).
Aerobic capacity is initially compromised after stroke, remaining low for many years following (MacKay-Lyons and Makrides, 2002; MacKay-Lyons et al., 2006). Stroke survivors who are ambulatory can generally perform at 50% of peak oxygen consumption and 70% of the peak power output that can be achieved by healthy adults, this is due to a range of factors including bed-rest induced deconditioning, concomitant left ventricular dysfunction, severity of neurological movement, and increased aerobic requirements of walking (Gordon et al., 2004). Reduced aerobic capacity raises risk of stroke reoccurring (MacKay-Lyons and Makrides, 2004). Aerobic exercise has also been shown to be associated with greater plasticity in the motor cortex (Murdoch et al., 2016), and aerobic exercise can increase adaptive neuroplasticity in stroke patients (Luft et al., 2008).
1.3.2 Cardiac Rehabilitation of Stroke Patients
Traditional Approaches
Traditional stroke rehabilitationcentre around neurological treatments such as the Bobath approach e.g. exercises for upper limbs, visual feedback, functional electrical stimulation, and use of orthotics and assistive devices, adapted according to the needs of each patient. This approach could currently be said to be the most popular amongst physiotherapists in the western world (Kollen et al., 2009). However, a number of studies in recent years have challenged the effectiveness of the Bobath approach. Paci (2003) found that the effectiveness of the approach was ‘questionable’ following a systematic literature search. The Bobath approach was also shown to be ineffective in improving patient gait (Lennon, 2006). It was also shown to have shortcomings in a systematic literature search by Kollen et al.(2009). They found that the Bobath approach was not more effective than other approaches in treating sensorimotor control of upper and lower limbs, dexterity, and mobility. It was also shown not be more cost-effective. Conventional stroke rehabilitation can allow patients to achieve functional independence but it does not adequately increase aerobic capacity (Mackay-Lyons and Makrides, 2002). Simultaneously, it can be expected that none of other associated effects, physical and cognitive, would be achieved by patients (see below).
A literature search by Eng and Tang (2007) on gait training as a form of rehabilitation for stroke victims showed that the use of gait training strategies such as neurodevelopmental techniques, muscle strengthening, treadmill training, and intensive mobility exercises had varying efficacy. Their study highlighted that improving gait was essential to patient recovery but showed that neurodevelopmental approaches such as Bobath were equivalent to and in some cases inferior to other approaches in gait retraining. They found that intensive mobility training that incorporates functional strengthening, balance and aerobic exercises and practice on a variety of walking tasks is most effective in increasing gait ability in stroke patients overall and suggested that a combination of ‘treadmill with task-specific practice may be optimal’.
Following a scholarly questioning of more traditional approaches such as the studies outlined above, there has accordingly been a recent paradigm shift in physiotherapy scholarship (Tyson, 2009). This is because of ‘an improved understanding of the mechanisms underlying adaptive motor relearning and mechanisms of functional recovery after stroke and includes metrics for measuring change’ (Carlisle, 2010). The focus is now on exercise and intensive practice interventions such as treadmill training. Task-repetitive training has proved to induce adaptive neuroplasticity, cortical and subcortical midbrain cerebellar networks can be activated by progressive locomotor-based exercise to improve walking in post-stroke patients (Luft et al., 2008). It is vital that physiotherapists use the best evidence available to them when employing rehabilitation approaches.
1.3.3 Cardiovascular Rehabilitation
As the above section (1.3.1) illustrated, there is a clear link between stroke and cardiovascular disease as stroke shares the same risk factors as other cardiovascular diseases while stroke also has a cardiovascular etymology. Almost all risk factors are shared by both stroke and cardiovascular disease, such as hypertension, diabetes, obesity, smoking, a sedentary lifestyle, stress, and hyperlipidaemia.Exercise has long been recognised to have health benefits such as lowering the risk of cardiovascular disease, improving mood, improving physical function, and reducing the risk of further stroke (Murdoch et al.2016). Regular cardiovascular exercise as many beneficial effects such as increased oxygen uptake (VO2), lowers blood pressure and prevents hypertension, increases endurance, increased blood flow to the central neuronal system, reduced effects of diabetes mellitus, and promotion of neurogenesis (Stoller, 2015, pp.2-3). As noted in the previous section, various studies such as Pandey et al., 2016 have shown that higher cardiovascular fitness in the middle age is associated with lower risk of stroke, even in those who already have other risk factors such as hypertension and diabetes mellitus.
Recently also, it has been discovered that exercise has cognitive benefits in enhancing cognitive flexibility, improving executive control and function, and enhancing motor learning (Masley et al.2009; Pontifex et al.2009; Roig et al.2012). Neuroplasticity is essential to stroke victims regaining functionality. It is thought that aerobic exercise induces neuroplasticity in the hippocampus and higher cardiovascular fitness levels in older adults are associated with greater volume of grey matter in this structure, which is associated with learning and memory (Murdoch et al., 2016).
After stroke, a complex pattern of cortical reorganisation occurs ‘in which the brain and central nervous system (CNS) adapt in response to environmental and behavioural change to acquire novel information by modifying neural connectivity and function’ (Linder et al., 2015). It is thought that aerobic exercise can induce neoplastic change in the motor cortex (Murdoch et al., 2016). Therefore ‘an intervention which promotes motor cortical reorganisation may have potential to improve functional outcomes, and quality of life, in stroke survivors’ (Murdoch et al., 2016). Cardiovascular rehabilitation can therefore promote neuroplasticity as well as aerobic fitness. A study by Blanchet et al. (2016) of chronic stroke patients with cognitive impairment living in the community has also shown that attention improved in the stroke survivors following an eight-week intervention with included an aerobic component, even without their cardio respiratory fitness changing.
Physical immobility in stroke patients leads to further medical problems such as physical deconditioning (Macko et al., 2005), but the fact that many stroke patients spend their time immobile in medical facilities may therefore hinder their recovery (Blennerhassett andDite, 2004). However, early intervention is essential to the full success of cardiovascular rehabilitation, and aerobic training can be safely and effectively implemented post-stroke (Pang et al., 2006).Some of the numerous benefits include improved cardio respiratory fitness, walking speed and endurance (Macko et al., 2005; Pang et al., 2006; Saunders, Greig et al., 2004).
Cardiovascular rehabilitation is well-established as a programme for those recovering from a cardiac event, but it has also shown by a number of studies to be a model of care for both inpatients and outpatients who are convalescing from stroke. While conventional stroke rehabilitation is solely aimed at helping patients regain functionality, cardiovascular rehabilitation also has a strong focus on exercise training and risk factor modification (Tang 2006, ii).It is important that the appropriate frequency, duration, and type of exercises are considered and that possible side effects are considered. Methods of control can involve identifying the heart rate, the rate of perceived exertion (BORG), or the direct VO2 so as to determine the intensity of the exercise is such to safely induce an aerobic training effect (Stoller, 2015, p.3).
Cardiovascular rehabilitation not only simply improves cardiovascular fitness, but a randomised trial has shown that task-repetitive training of the lower extremity can stimulate adaptive neuroplasticity and improve patient gait (Luft et al., 2008).Therefore, cardiovascular rehabilitation has both neurological and physical benefits in improving functional mobility and patients’ quality of life. Another study by Linder et al.(2015) showed that the participant, a stroke patient, experienced improved motor outcomes and improvement in all but one non-motor outcome following 24 sessions of forced aerobic exercise, comprising 45 minute sessions of forced exercise on a motorised stationary bike followed by another 45 minutes of upper-extremity repetitive task practice (Linder et al., 2015). Linder et al. (2015) concluded that the development of a rehabilitative intervention for people with stroke that facilitates motor recovery while simultaneously decreasing cardiovascular risk factors would be a valuable adjunct to current stroke rehabilitation approaches.
A randomised trial of 88 men with coronary artery disease and disability, two thirds of who were stroke survivors, showed significant increases in peak left ventricular ejection fraction and high-density lipoprotein cholesterol and decreases in resting heart rate and total serum cholesterol, following six months of a home exercise training programme (Fletcher et al., 1994). A randomised clinical trial involving treadmill exercise indicates that cardiovascular rehabilitation of stroke patients not only helps in their ability to move but also enables the patient to walk properly and have a quicker recovery (Macko et al., 2005). Aerobic exercise improved cardiovascular fitness as well as functional mobility and proved more effective than other forms of stroke rehabilitation in terms of improvement in peak VO2 and six-minute walk tests (Macko et al., 2005).
Similarly, Tang et al. (2009) added thirty minutes of cycle ergometer to conventional stroke rehabilitation and found improvement in peak VO2 and six-minute walk tests. A randomised trial that included task-orientated activity additional to conventional stroke rehabilitation was shown to be effective by Blennerhassett and Dite (2004) and Rensink et al. (2009). Another 2009 study indicated that blood pressure is lowered and hyperlipidaemia is reduced by moderate intensity cycle training (Rimmer et al., 2009).
A study led by Dr Susan Marzolini presented at the Canadian Stroke Congress 2013 indicated that stroke patients who participated in a cardiovascular rehabilitation programme for six months saw a 21% improvement in the strength and range of motion of weakened limbs, a 19% improvement in speed of walking, and a 16% improvement in distance walked (Heart and Stroke Foundation, 2013). Improvements not only occur in strength, endurance, and functional status, but also reduce cardiovascular disease risk factors (Rahl, 2010, p.236), which, as highlighted above, are greater in stroke survivors than healthy adults in general. A trial by Ivey et al. (2007) indicated treadmill aerobic training reduced insulin sensitivity and glucose intolerance, factors which can lead to worsening of cardiovascular disease and reoccurrence of stroke.
Aerobic training modes generally ‘include leg, arm, or combined arm-leg ergometer at 40% to 70% of peak oxygen consumption or heart rate reserve, with perceived exertion used as an adjunctive intensity modulator’ (Gordon et al., 2004). Gordon et al., 2004 recommend frequency of training 3-7 days a week with a duration of 20-60 minutes of continuous or accumulated exercise, such as 10 minute bouts, depending on the patient’s fitness level, as intermittent training may be needed initially due to the extreme deconditioning of some patients (Gordon et al., 2004).
Gordon et al. (2004) also provide an exercised programme based around aerobic, strength, flexibility, and neuromuscular modes. They suggest aerobic exercise involve large muscle activities, such as walking, arm and leg ergometry, treadmill, stationary cycle, arm ergometry and seated stepper, at least three non-consecutive days a week in 20-60 minute sessions, at 40-70% VO (oxygen consumption) and HR (heart-rate) reserve. This is aimed at increasing independence, walking speed, and aerobic capacity as well as reducing the risk of cardiovascular disease (Gordon et al., 2004; Durstine et al., 2008).
Circuit training at 40-50% maximal voluntary contraction is recommended 2-3 days a week utilising 1-3 sets of 10-15 repetitions and involving 8-10 exercises working different muscle groups, increasing resistance over time; weight machines, free weights (2-3 days a week), and isometric exercise can also be elements (Gordon et al., 2004; Durstine et al., 2008). It is aimed at increasing muscle strength and endurance, and ability to perform leisure and occupational activities and ADL (activity of daily living). Flexibility exercise is based around stretching through upper and lower body ROM (range of motion) activities aimed at decreasing risk of injury and involving static stretches held for 10-30 seconds 2-3 days a week (Gordon et al., 2004, Table 1; Durstine et al., 2008, Table 25.1).However, Gordon et al.(2004) also recommend exercise programmes be tailored to each patient based on their unique barriers, adapted to their needs e.g. use of handrails, arm cycle ergometry, arm-leg or leg cycle ergometry.
A cardiac rehabilitation programme should not only include specialised exercise, but also education and counselling (Tang, 2006, 22).Cardiovascular rehabilitation should be long-term and continue beyond six months in duration (Gordon et al., 2004).It is essential that patients exercise sufficiently in the course of a cardiovascular rehabilitation to induce a training effect as there is a risk that some approaches do not push the patient to work hard enough (Mackay-Lyons and Makrides 2002). Kuys, Brauer and Ada (2006) found that conventional stroke rehabilitation approaches failed to induce an adequate cardiovascular training effect post-stroke. Because of both the physical and psychological benefits cardiovascular rehabilitation is worth pursuing even in patients with severe levels of impairment.
While stroke patients can be limited by impairments, physiotherapists can tailor cardiovascular rehabilitation programmes to meet the needs of clients so that both mild-moderate and moderate-severely impaired patients can safely practice cardiovascular rehabilitation (Ting et al., 2016, p.13). Increased supervision is necessary in relation to stroke patients (Ting et al., 2016, p.13). Commencing a cardiovascular research programme in severely impaired stroke patients can be complicated by their condition and associated comorbidities, but it has been shown that inactivity post-stroke can lead to major deconditioning and overall worsening of functional aerobic impairment, therefore early intervention is essential (Mackay and Makrides, 2002). Ivey et al. (2011, p.79) highlight that due to the varying exercise capacity and medical history of various stroke patients, it is essential that cardiovascular exercise programmes take each individual’s needs into account and that heart rate monitoring and Ratings of Perceived Exertion scales be used to gauge patient exercise tolerance.
Cardiovascular rehabilitation programmes are not utilised effectively in Ireland, despite need for research into cardiovascular rehabilitation programmes being previously highlighted by The Irish Heart Foundation (2000). Although they have been proven to be effective for stroke patients, as highlighted above, cardiovascular rehabilitation programmes are generally only offered to people after a cardiac event such as a heart attack or bypass surgery and not stroke patients. In February 2016 the Irish Heart Foundation recorded that only one hospital in Ireland has access to a specialist community stroke rehabilitation team and also noted that only 29% of patients were admitted directly to a stroke unit. It was also noted that there was a deficit of 50% in physiotherapists (Irish Heart Foundation, 2016, 9).
Baggot Street Community Hospital has a specialised stroke rehabilitation unit, and a randomised control trial was carried out here in 2003 to evaluate the effects of a cardiovascular rehabilitation programme (Lennon et al., 2006; Lennon et al., 2008). 48 community-dwelling subjects who had suffered a stroke 1-12 years earlier received 6 sessions of 30 minutes’ cycle ergometry training set at 50-60% of their maximal heart rate in a controlled environment and were shown to improve their cardiovascular fitness and also reported improvements in quality of life (Lennon et al., 2006, 212). Apart from this study there appears to be limited research undertaken in an Irish context.
Stroke and heart disease are increasingly major causes of mortality and disability worldwide. Research indicates the close link between stroke and cardiovascular disease, while high cardio respiratory fitness in general can prevent occurrence of stroke. Research has also shown the positive impact cardiovascular rehabilitation can have on stroke patients. Studies have shown that the benefits include improved physical fitness and reduction of risk factors; patients have increased ambulatory function, increased strength, increased cognition and overall a better quality of life, while their chances of stroke reoccurring are reduced. The importance of maintaining the programme long-term beyond several months after stroke is emphasised. It is also vital that the programme is started as soon as possible post-stroke. Even patients with moderate-severe impairment can exercise safely though appropriate facilities and supervision are required and programmes need to be modified according to patients’ needs and condition. It is important however that the level of exertion is sufficient to induce the desired effect.
Despite the clear potential of cardiovascular rehabilitation to improve the health of the Irish population and prevent secondary reoccurrence of stroke as well disability, there seems to be a lack of understanding and awareness regarding this type of rehabilitation in Ireland. This research is therefore of benefit in highlighting the positive effects of cardiovascular rehabilitation on stroke patients as well as the obstacles preventing Irish physiotherapists from carrying it out. The next chapter presents the methodology for the study undertaken.