Physiotherapy, Physical Exercise and Stroke: What you need to know

APA Neurological Physiotherapist Natalie Fini answers your questions about how physiotherapy can help you to maintain physical activity throughout your rehabilitation. If you have any comments or questions about the information supplied here, or about neurological physiotherapy and stroke in general, please do not hesitate to contact us.

1. Why is physical activity important, especially for stroke survivors?

Keeping physically active—throughout all walks of life—is vitally important for everyone. Physical activity is known to be beneficial in helping to prevent a range of chronic health conditions including stroke, heart disease, diabetes, dementia, osteoporosis and various cancers.

Physical activity also helps to lower your blood pressure and cholesterol, both of which are risk factors for a number of diseases.

On a lighter note, being physically active also makes you feel good! In addition to a wide range of benefits, physical activity can help to improve your mood and decrease your fatigue.

2. How much physical activity should people be doing?

Australian recommendations state that we should be doing up to 150 minutes of moderate-intensity physical activity per week. This equates to around 30 minutes of exercise that makes you "puff" a little, but still be able to talk easily - for example brisk walking - at least five times per week. Unfortunately, most Australians don't meet these guidelines.

The guidelines have now been expanded further to include recommendations about breaking up sitting time. They now recommend minimising the amount of time we spend in prolonged sitting and to break up periods of sitting as often as possible - for example stand up and walk around for five minutes every 30-60 minutes.

The American Heart and Stroke Association have also released exercise and physical activity guidelines specifically for stroke survivors. They recommend that stroke survivors do 20-60 minutes of aerobic activity three to five days per week, and strength, balance, and flexibility exercises two to three days per week.

These targets may be hard to achieve for some people, but don't despair; even increasing your physical activity by small amounts can have beneficial effects. New and emerging research is beginning to show the benefits of ‘light intensity physical activity’, which includes everyday activities - such as doing chores around the house!

Another simple measure of physical activity is the amount of steps you take every day. We’ve all heard about the magical number ‘10,000’, but experts have recommended that those with a disability should take something more like 6,500-8,500 steps per day. This is another measure that can be used and can be measured by wearable activity monitors that are currently quite popular.

3. How physically active are stroke survivors?

People who have experienced a stroke—regardless of whether they are in the acute phase (just experienced a stroke), in the three month period following their stroke, or more than six months has passed since their stroke—typically spend at least 78% of their waking day sitting or lying down.

Unfortunately, in the chronic stage (more than six months following a stroke) stroke survivors take, on average, only 4,078 steps per day. This is less than half of the daily activity undertaken by healthy people, and is far less than the recommended levels, even for those with limited capacity.

4. Why don’t stroke survivors do enough physical activity?

This is a complex question, and there are many factors that play a role. For example:

• Level of physical disability
• Fatigue
• Mood disorders such as anxiety and depression, which are known to be high among stroke survivors
• Cognitive changes (thinking, memory and problem solving)
• Lack of social support
• Lack of transport or funding for activities
• Loss of confidence
• They don't think they can.

5. How can stroke survivors become more active?

Everyone is able to address barriers to undertaking physical activity! However, if you struggle, health professionals experienced in stroke care can certainly help.

An easy place to start is to gradually increase the frequency of light jobs you do around the house (for example cleaning, vacuuming and dusting) or increase the amount of steps you take each day. Though this might sound scary or tiresome initially, in reality this change could be as small as walking for an extra one minute per day, and slowly increasing this every few days.

If you’re nervous about starting to exercise, here are a few tips for you to remember:

• Always start small
• Keep in mind that you should always be able to talk while you are being active or exercising
• You should always get the OK from your GP, rehabilitation specialist or neurologist before you embark on a new exercise program. In some cases they might recommend that you have formal exercise testing.

6. How can physiotherapy help me to become more active?

Physiotherapists are experts at prescribing exercise, and providing physical activity options and recommendations, for people with neurological diagnoses - including stroke. All physiotherapists have theoretical and practical training, based in a clinical setting, to fulfill the requirements of their degree.

Further, there are a group of physiotherapists who have undergone additional training through professional development courses and / or formal postgraduate training, to specialise in the area of neurology. They usually call themselves neurological physiotherapists and these people have extensive experience working with people who have experienced a stroke.

Neurological physiotherapists work in a variety of settings: hospital, in and outpatient departments, community rehabilitation and community health settings, and in private practice.

7. What about obstacles to physical activity, such as stiffness, weakness, fatigue?

These issues can certainly make someone reluctant to be active! However, exercise often improves stiffness, weakness and fatigue. In this case, exercise really can be the best medicine!

One thing people with stroke need to be aware of is that you often have a higher risk of falling. This is where it can be important to speak to your physiotherapist about choosing the right form of activity and exercise as they can help to minimise your risk of falling or other injuries.

Also, as we age, we all become more prone to developing aches, pains and musculoskeletal injuries. Once again, correct exercise and physical activity prescription and design, specific to you, is important here. It doesn’t have to all feel like work, though - physiotherapists are always happy to talk to you about the types of activities that you enjoy doing, and incorporate these into your plan!

8. Is there a fear of people pushing themselves too far, and causing another stroke?

Although this is not a common occurrence, it is why we recommend that you get clearance from your doctor before embarking on a new exercise program. In some instances, formal exercise testing may be recommended.

9. To sum up:

Give it a go! Set yourself a goal - it doesn't matter how big or small it is. Small changes are important too - especially if they get you started!

Most importantly choose a form of exercise or activity that you like - you are more likely to stick at it!

Some final tips include:

• Make it part of your routine
• Exercise with a friend (that way you're accountable)
• Try to break up your sitting time and do more light jobs around the house.

References:

1. Australia's Physical Activity and Sedentary Behaviour Guidelines In: Australian Government DoH, editor. 2014.
2. Billinger, S.A., Arena, R., Bernhardt, J., et al., Physical activity and exercise recommendations for stroke survivors: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014: p. 1-22.
3. Warburton, D.E.R. & Bredin, S.S.D. Health benefits of physical activity: a systematic review of current systematic reviews. Curr Opin Cardiol 2017, 32:000–000.
4. Tudor-Locke C, Craig CL, Aoyagi Y, et al. How many steps/day are enough? For older adults and special populations. International Journal of Behavioral Nutrition and Physical Activity. 2011;8:80.
5. Fini NA, Holland AE, Keating J, et al. How physically active are people following stroke? Systematic review and quantitative synthesis. Phys Ther. 2017;97 (7):707–717