Sandra A. Billinger

PURPOSE: This scientific statement provides an overview of the evidence on physical activity and exercise recommendations for stroke survivors. Evidence suggests that stroke survivors experience physical deconditioning and lead sedentary lifestyles. Therefore, this updated scientific statement serves as an overall guide for practitioners to gain a better understanding of the benefits of physical activity and recommendations for prescribing exercise for stroke survivors across all stages of recovery. METHODS: Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association's Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and indicate gaps in current knowledge. RESULTS: Physical inactivity after stroke is highly prevalent. The assessed body of evidence clearly supports the use of exercise training (both aerobic and strength training) for stroke survivors. Exercise training improves functional capacity, the ability to perform activities of daily living, and quality of life, and it reduces the risk for subsequent cardiovascular events. Physical activity goals and exercise prescription for stroke survivors need to be customized for the individual to maximize long-term adherence. CONCLUSIONS: The recommendation from this writing group is that physical activity and exercise prescription should be incorporated into the management of stroke survivors. The promotion of physical activity in stroke survivors should emphasize low- to moderate-intensity aerobic activity, muscle-strengthening activity, reduction of sedentary behavior, and risk management for secondary prevention of stroke.

Certified rehabilitation counselors www.crccertification.com Assist individuals with disabilities to maximize their vocational and avocational living goals in the most integrated setting possible through the application of the counseling process, including vocational and counseling, case management, referral, and service coordination; identifying and addressing employment and attitudinal barriers; and job analysis, development, and placement services. Neuropsychologists www.apa.org Specialize in brain-behavior relationships and have extensive training in anatomy, physiology, and neuropathology. They identify and treat cognitive and neurobehavioral dysfunction, and through assessment also monitor recovery and thereby enhance community reintegration. Occupational therapists www.aota.org Focus on the "skills of living" necessary for independent and satisfying living. OT services include customized treatment programs to perform daily activities, comprehensive home and job site evaluations and adaptation recommendations, performance skills assessment and interventions, adaptive equipment recommendations and training, and family and caregiver education. Rehabilitation nurses (RNs) www.rehabnurse.org Manage complex medical issues, provide ongoing patient and caregiver education, and establish care plans to maintain optimal wellness. RNs use a holistic approach to fulfill patients' medical, environmental, spiritual, vocational, and educational needs via principles from other disciplines and their own unique medical expertise (bowel, bladder, and skin management). In all care settings, RNs function as coordinators/case managers, collaborators, and counselors. A registered nurse with at least 2 years of practice in rehabilitation who passes the Association of Rehabilitation Nurses examination can earn the Certified Rehabilitation Nurse distinction. Physical therapists www.apta.org Experts in examining and treating neuromuscular problems that affect the abilities of individuals to move. PTs practice in many settings and with all age groups. Physicians www.aapmr.org Usually coordinate the rehabilitation team and manage medical conditions pertaining to stroke and comorbidities. A physician may be a physiatrist (ie, specializing in physical medicine and rehabilitation and thus restoration of function in individuals with problems that range from simple physical mobility to more complex cognitive issues). Recreational therapists www.atra-online.com Provide treatment services and recreation activities to individuals with disabilities to facilitate independent physical, cognitive, emotional, and social functioning by enhancing individuals' current skills and assisting new skill development for daily living and community function. Besides discharge planning for community reintegration, they help individuals develop or redevelop social, discretionary time, decision-making, coping, self-advocacy, and basic skills to enhance overall quality of life. Social workers www.naswdc.org Assist individuals, groups, or communities restore or enhance their capacity for social functioning, while creating societal conditions favorable to their goals. Requires knowledge of human development and behavior; social, economic, and cultural institutions; and interactions among these factors. Social workers help prevent crises; counsel individuals, families, and communities to facilitate coping with everyday stresses; and identify resources to allow individuals with disabilities to remain in the community. SLPs www.asha.org Assess speech, language and other cognitive functions, as well as swallowing, and provide interventions and counseling/education to address language and speech disorders (eg, aphasia, apraxia of speech, dysarthria, and cognitive-communication impairment). SLPs also intervene when swallowing and cognitive disorders exist. They provide services to all age groups and in all care settings. RN indicates rehabilitation nurse. Downloaded from http://ahajournals.org by on August 11, 2023

Physical inactivity is one of the most prevalent major health risk factors, with 8 in 10 US adults not meeting aerobic and muscle-strengthening guidelines, and is associated with a high burden of cardiovascular disease. Improving and maintaining recommended levels of physical activity leads to reductions in metabolic, hemodynamic, functional, body composition, and epigenetic risk factors for noncommunicable chronic diseases. Physical activity also has a significant role, in many cases comparable or superior to drug interventions, in the prevention and management of >40 conditions such as diabetes mellitus, cancer, cardiovascular disease, obesity, depression, Alzheimer disease, and arthritis. Whereas most of the modifiable cardiovascular disease risk factors included in the American Heart Association's My Life Check - Life's Simple 7 are evaluated routinely in clinical practice (glucose and lipid profiles, blood pressure, obesity, and smoking), physical activity is typically not assessed. The purpose of this statement is to provide a comprehensive review of the evidence on the feasibility, validity, and effectiveness of assessing and promoting physical activity in healthcare settings for adult patients. It also adds concrete recommendations for healthcare systems, clinical and community care providers, fitness professionals, the technology industry, and other stakeholders in order to catalyze increased adoption of physical activity assessment and promotion in healthcare settings and to contribute to meeting the American Heart Association's 2020 Impact Goals.

BACKGROUND: There is increasing interest in the role of physical exercise as a therapeutic strategy for individuals with Alzheimer's disease (AD). We assessed the effect of 26 weeks (6 months) of a supervised aerobic exercise program on memory, executive function, functional ability and depression in early AD. METHODS AND FINDINGS: This study was a 26-week randomized controlled trial comparing the effects of 150 minutes per week of aerobic exercise vs. non-aerobic stretching and toning control intervention in individuals with early AD. A total of 76 well-characterized older adults with probable AD (mean age 72.9 [7.7]) were enrolled and 68 participants completed the study. Exercise was conducted with supervision and monitoring by trained exercise specialists. Neuropsychological tests and surveys were conducted at baseline,13, and 26 weeks to assess memory and executive function composite scores, functional ability (Disability Assessment for Dementia), and depressive symptoms (Cornell Scale for Depression in Dementia). Cardiorespiratory fitness testing and brain MRI was performed at baseline and 26 weeks. Aerobic exercise was associated with a modest gain in functional ability (Disability Assessment for Dementia) compared to individuals in the ST group (X2 = 8.2, p = 0.02). There was no clear effect of intervention on other primary outcome measures of Memory, Executive Function, or depressive symptoms. However, secondary analyses revealed that change in cardiorespiratory fitness was positively correlated with change in memory performance and bilateral hippocampal volume. CONCLUSIONS: Aerobic exercise in early AD is associated with benefits in functional ability. Exercise-related gains in cardiorespiratory fitness were associated with improved memory performance and reduced hippocampal atrophy, suggesting cardiorespiratory fitness gains may be important in driving brain benefits. TRIAL REGISTRATION: ClinicalTrials.gov NCT01128361.

Most stroke survivors have very low levels of cardiovascular fitness, which limits mobility and leads to further physical deconditioning, increased sedentary behavior, and heightened risk of recurrent stroke. Although clinical guidelines recommend that aerobic exercise be a part of routine stroke rehabilitation, clinical uptake has been suboptimal. In 2013, an international group of stroke rehabilitation experts developed a user-friendly set of recommendations to guide screening and prescription-the Aerobic Exercise Recommendations to Optimize Best Practices in Care after Stroke (AEROBICS 2013). The objective of this project was to update AEROBICS 2013 using the highest quality of evidence currently available. The first step was to conduct a comprehensive review of literature from 2012 to 2018 related to aerobic exercise poststroke. A working group of the original consensus panel members drafted revisions based on synthesis. An iterative process was used to achieve agreement among all panel members. Final revisions included: (1) addition of 115 new references to replace or augment those in the original AEROBICS document, (2) rewording of the original recommendations and supporting material, and (3) addition of 2 new recommendations regarding prescription. The quality of evidence from which these recommendations were derived ranged from low to high. The AEROBICS 2019 Update should make it easier for clinicians to screen for, and prescribe, aerobic exercise in stroke rehabilitation. Clinical implementation will not only help to narrow the gap between evidence and practice but also reduce current variability and uncertainty regarding the role of aerobic exercise in recovery after stroke.