Interview with Physiatrist Dr. Elizabeth Pegg Frates

Updated:Aug 11,2010

1) What are the benefits of physical activity for stroke survivors?
2) Are there any research studies that quantify the benefit to survivors of participating in a physical activity program?
3) The typical exercise prescription for healthy people is at least 30 minutes most days of week….how should stroke survivors modify the exercise prescription?
4) What advice can you give our readers about resistance training after stroke?
5) Have you found a motivation strategy that works for getting stroke survivors to engage in physical activity?
6) What de-motivates someone?
7) What should a stroke family look for when evaluating a physical activity program?
8) What is your opinion of the “Wii-hab” phenomenon (using video games like the Wii for physical activity)?
9) Are there any warning signs that a family caregiver can look for that physical activity may be causing a problem?
10) Can physical therapists help survivors modify traditional physical activity programs?
11) What advice would you give a survivor who wants to take up physical activity but hasn’t engaged in physical activity since the stroke?
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1) What are the benefits of physical activity for stroke survivors?

There are several benefits of physical activity for stroke survivors.   In terms of their cardiovascular systems, regular exercise helps improve the lipid profile by lowering cholesterol and raising HDL (the good cholesterol that helps clear out the bad cholesterol).  It also helps reduce blood pressure and resting heart rate.  Regular exercise can help improve blood sugar levels and increase insulin sensitivity (reducing the risk of diabetes or the severity of it).  In terms of their psychological well being, regular physical activity helps reduce feelings of depression and anxiety.  In terms of function, regular exercise helps increase endurance and strength which can help survivors perform their ADL’s with less fatigue and with greater ease.  Physical activity will help the stroke survivor lose weight, if that is an issue. 

Many of these benefits of physical activity can help the stroke survivor prevent a second stroke.  Risk factors for stroke include high cholesterol, high blood pressure, diabetes, obesity, and physical inactivity.  Regular exercise addresses all of these risk factors.

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2) Are there any research studies that quantify the benefit to survivors of participating in a physical activity program?

The American College of Sports Medicine has worked hard to summarize data from the medical literature on the evidence for inverse dose-response relationships between physical activity and health outcomes.  They have published their findings in the book, ACSM’s Guidelines for Exercise Testing and Prescription, Seventh Edition, Lippincott Williams and Wilkins, 2006.

There is scientific research in the form of uncontrolled studies, nonrandomized trials and observational studies that there is an inverse dose-response relationship between physical activity and all cause mortality, cardiovascular and coronary heart disease, and type 2 diabetes.  This means the more physical activity you get, the less likely you are to suffer a stroke, heart attack, and type 2 diabetes.

Research also shows that if someone changes from being sedentary to being physically active, he will have lower rates of disease and pre-mature death compared to his counterparts who remain sedentary.

It is never too late to get active and to reap the benefits of physical activity.

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3) The typical exercise prescription for healthy people is at least 30 minutes most days of week….how should stroke survivors modify the exercise prescription?

A stroke survivor should speak with their physician before starting any physical activity program. Physical activity is safe only when your physician says it is safe.

The exercise prescription needs to be individualized for each stroke patient based on their interests, strengths and current level of fitness.   There are four parts to the exercise prescription: type, intensity, duration, and frequency.  There are several options for the type of physical activity to be used in the exercise prescription.  For stroke survivors, the main consideration is their functional ability. 

In the book, Life After Stroke:  The Guide to Recovering Your Health and Preventing Another Stroke, we created four categories of stroke survivors to help with selecting an appropriate type of physical activity for the prescription.  The categories are not hard and fast and a survivor may move from one category to another with time, hard work, and therapy. The four categories are as follows:

Severe functional limitations:  An example of a stroke survivor who falls into this category is someone who requires a great deal of help with activities of daily living, requires assistance of two people for transfers, and is using a wheelchair for ambulation.  You might think that physical activity is not an option for this category, but it is.  Any physical activity is better than none.  The physical activity does not need to be walking or jogging to provide benefits to the stroke survivor.  For example, for stroke patients with severe functional limitations, many of their physical activities can be sitting in a chair.  Going from head to toe, they can perform neck stretches and ROM (range of motions) exercises including flexing, extending and lateral rotation.  They can do shoulder raises and rotations.  For their arms, they can do circles as well as ROM exercises flexing and extending their elbows and wrists.  For their fingers, they can work on making fists and wiggling each finger.  They can also squeeze a therapy ball.  For the legs, they can do leg lifts while sitting in a chair.  They can do ROM exercises flexing and extending their knees.   For the ankles, they can perform ankle rotations as well as ROM exercises flexing and extending their ankles.  A therapist or trained family member can assist with a weak limb and help put that limb through ROM exercises.

Moderate functional limitations:  An example of a stroke survivor who falls into this category is someone who is unable to move an arm and a leg at all, or may have increased tone in an arm or leg which makes moving it difficult.  Someone in this category may be able to perform ADLs with their unaffected limbs and may be working on walking with a walker.  A survivor in this category can perform all the   physical activities listed in the previous category and more.  For example, the pool might be a good option for an physical activity venue.  If sitting balance is good, then a recumbent bicycle or recumbent stepper might be a good option.  A therapist or trained family member may need to help the survivor manage their weak limb while performing these physical activities.  An upper extremity exercise machine might also be a good option as they are similar to stationary bicycles but the levers are for the hands not the feet.  There are also exercise machines with both arm levers and leg levers which can be utilized.  The affected limb will need to be stabilized with the aid of another person.

Mild functional limitations: An example of a stroke survivor who falls in this category is someone who has weakness on one side or in one limb, but they are still able to move all four limbs and engage in physical activity with them.  They are probably able to perform ADLs independently and are walking with the assistance of a cane or an ankle foot orthosis (AFO).  At this level, there are many options including swimming or walking.  A survivor in this category might be able to use a stationary bicycle using a Velcro strap to stabilize the weak foot or by having a therapist or trained family member help them.

Minimal to no functional limitations: A stroke survivor in this category is most likely independent with walking and ADLs.  Walking, jogging, bike riding, tennis, golf, soccer, dancing and tennis are just a few options for survivors in this category.

Selecting the type of physical activity that is appropriate for the stroke survivor is important.

As for the intensity of the physical activity, this will depend on the endurance and physical fitness of the survivor.  The survivor will need to discuss the level of intensity with his physician.  A physical activity session that is completed at a low intensity is better than no exercise session at all.  A moderate intensity of physical activity is a goal that is recommended for asymptomatic healthy individuals.  At a moderate intensity level, the person exercising can talk but not sing.  This might be possible for some stroke survivors depending on their heart health and overall fitness level.

As for duration of the physical activity session, 30-45 minute sessions are the ultimate goal.   However, a stroke survivor who has been lying in bed will have experienced significant muscle atrophy and deconditioning which needs to be taken into consideration when prescribing physical activity.  A reasonable initial goal for someone in that condition is to accumulate 10 minutes of exercise.  This can be broken up into two sessions of five minutes, one in the morning and one in the afternoon.  With the guidance of their physician, the survivor might be able to add another five minutes to the session depending how things are going. 

As for frequency, it is recommended that people engage in physical activity most days of the week.  The frequency of physical activity needs to be individualized and worked out with a physician.  In some cases, a stroke survivor might start out with a goal of exercising three times a week.   With time, the stroke survivor will increase endurance and strength and be able to increase the frequency.  It is best to progress at a slow and steady pace that is comfortable for the stroke survivor.  Again, it is important to work closely with your physician to determine the most appropriate frequency of physical activity.

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4) What advice can you give our readers about resistance training after stroke?

Resistance training can increase muscle mass and strength which can translate into increased mobility, greater independence, and improved function with daily activities.  Each stroke survivor should talk about resistance training with his own physician before beginning a program.

Type: weight lifting, using exercise bands and working out on Nautilus machines are two different types of resistance training exercises.

Intensity: pick a weight that is not too heavy (one that you can only lift six times) and not too light (one that you can lift easily more than 15 times). 

Duration:   It is generally recommended to start with ten to fifteen repetitions of a weight lifting exercise.  This would be considered a set.  If possible, work eight to ten different areas of your body such as your arms, shoulders, chest, trunk, back, hips, legs, and ankles.  After completing one set of exercises, a fifteen second rest is recommended.   

Frequency: Resistance training is generally recommended two times a week, not on consecutive days to allow rest time for the muscles to recuperate.  Resting for at least fifteen seconds between sets is recommended.

It is important to discuss starting a resistance training program with your physician to make sure you are medically cleared for such an activity.  After being cleared to begin, it is important to talk with a physical therapist or exercise specialist about the proper technique for the activity you choose.  For example, with weight lifting, it is recommended that the survivor breath normally while performing a set of repetition and not hold his breath as this can increase blood pressure.  Lifting weights improperly can result in musculoskeletal injury.  Thus, going to a cardiovascular rehabilitation facility associated with a hospital is often a good choice as there will be proper supervision for a stroke survivor.  Not all stroke survivors need the same amount of supervision.  Depending on functional level, strength, cardiac health and other health conditions, stroke survivors will have different physical activity prescriptions for resistance training.

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5) Have you found a motivation strategy that works for getting stroke survivors to engage in physical activity?

Stroke survivors are a diverse group of individuals.  Their motivations for exercising will vary from survivor to survivor.  The best advice is to approach the motivational strategy as we do the physical activity prescription – on an individual level.  What motivates one person might not move another.  So the question is what moves the survivor?  The person who can best answer this question is the survivor.  After discussing the benefits of physical activity with a stroke survivor, you could ask them which one of those benefits seems most important to him.  Whatever the answer – losing weight, reducing blood pressure or improving mood, focus on that motivator because it is the one that speaks to the survivor.

After coming up with a personal motivator, then there is some strategy as to how to initiate a physical activity program.   As with any behavior change, it is important to take small attainable steps that are achievable and will ultimately lead to success.  People are more likely to stick with a behavior change, if they feel successful at it. 

Setting up an ultimate goal for physical activity – what the stroke survivor would like to be doing in three months is a good place to start.   Realizing it will take three months to get there, focus on the next week.  The first concrete goal for physical activity is one that deals with the first week.  For example, a reasonable goal for a stroke survivor who has mild functional limitations and had been sedentary for years would be to engage in physical activity for ten minutes three days of the week and try to select the three days that will work for the schedule that particular week.  Selecting the time of day and putting it in a calendar for the stroke survivor is also helpful.

Apart from setting specific attainable weekly goals, a stroke survivor can also keep an physical activity log and chart their sessions.  This can be posted on the refrigerator or a mirror and can act as a reminder.

Another good motivational tool is a buddy.  Exercising with a buddy is more fun and is also a way to make the stroke survivor accountable for sticking to a specific time and day. Joining an exercise group is another helpful motivator for some. Participating in a race such as Train to End Stroke can be a powerful motivator for many.

One of the most important motivating factors for stroke patients is the social support of their family and friends.  Checking in with the stroke survivor about his exercise program, participating in a physical activity session with the survivor, and congratulating him on any and all completed physical activity sessions are ways to show your support.

6) What de-motivates someone?

For stroke survivors who have not been involved with routine physical activity, just the thought of a physical activity session can be daunting.  Recommending that the stroke survivor attempt to do too much too fast is one sure way to de-motivate him.  It is a set up for failure.  The recommendation for adults to do a minimum of 30 minutes of physical activity on most days of the week does not need to be the first thing the stroke survivor hears.  This can be over whelming.  Small successful steps are the way to long lasting change.

Selecting a physical activity that the stroke survivor does not really like can be de-motivating.   The survivor’s family and friends might think that pool exercises are a great idea, but the survivor might not even want to put on a bathing suit and get in the pool.   It is important to talk with the stroke survivor and find a physical activity that they are interested in trying.  

Boredom with a physical activity program is another way that people are de-motivated about physical activity.  Checking in with the survivor and seeing if the type of physical activity they are performing is still engaging and interesting to them is important.  There are a number of different physical activity options for all levels of functional limitations.  Varying the type of physical activity can be one way to keep stroke survivors motivated.

7) What should a stroke family look for when evaluating a physical activity program?

This depends on the health conditions and functional level of the stroke survivor. The exercise prescription needs to be individualized.

8) What is your opinion of the “Wii-hab” phenomenon (using video games like the Wii for physical activity)?

The visual reality rehabilitation devices such as wii baseball, wii golf, wii wrestling, and wii bowling offer some benefits to stroke survivors.  Using these devices gives instant feedback on skills which can be motivating.  There are few published studies on the benefits of these devices.  However, there are anecdotal benefits including enhanced compliance with training sessions and increased time in training sessions.  Many stroke survivors find the wii fun and want to use it.  Visual reality rehabilitation will become more and more popular as more devices are invented.  There are many different devices available now. Some simulate driving a car.  Some simulate walking in a house.  Some can simulate flying a plane with ankle movements.  These devices seem to enhance motivation, provide active movement around joints, allow for repetition in an engaging setting, and create an interactive interface for the stroke survivor.  It will be interesting to see what scientific research will tell us about the usefulness of such devices in terms of improving function.

9) Are there any warning signs that a family caregiver can look for that physical activity may be causing a problem?

Exercise sessions should be terminated if the stroke survivor is experiencing:

Chest pain
Wheezing
Leg cramps
Excessive fatigue
Dizziness
Near syncope (fainting)

10) Can physical therapists help survivors modify traditional physical activity programs?

Yes, definitely….it takes creativity and problem-solving skills to develop a physical activity plan for stroke survivors with functional limitations.

11) What advice would you give a survivor who wants to take up physical activity but hasn’t engaged in physical activity since the stroke?

It is never too late to start exercising. 

Research also shows that if someone changes from being sedentary to being physically active, he will have lower rates of disease and pre-mature death compared to his counterparts who remain sedentary.

Realize that some physical activity is better than none.  Have a realistic vision of what you would like to be doing in three months.  Set reasonable, attainable weekly goals to help you attain that vision.  Carefully consider your options for type of physical activity. Select something you enjoy.  If you do not know anything that you enjoy, be open to trying a physical activity for a week or two and if you are not happy or successful, then be willing to try something new.  Personalize it.  Do it for yourself.  There are several benefits of physical activity.  Decide which benefit means the most to you. Consider:

  • Your motivators – ask yourself why you want to engage in physical activity and focus on the one motivator that means the most to you.
  • Your potential obstacles – think about the things that might get in the way of your participating in your physical activity program and problem solve how to get around them.
  • Your strengths – think about times when you have tried something new in the past and been successful with it. What aspects of your personality helped you succeed?   Was it your hard work? Your perseverance? Your easy going nature? Your creativity?  Your optimistic attitude? Your ability to laugh at yourself when things went wrong?  Identify some of your strengths that you can use to help you make the transition from being sedentary to being physically active. You can do it.

Remember consult your physician before starting a physical activity program. Physical activity is safe only when your physician says it is safe.