A major objective of this study was to assess the effectiveness of APA-stroke in a community-based population of patients with moderate hemiparetic disability. The main outcome was gait velocity, a measure strongly associated with both indoor and outdoor disability.42,43
A clear-cut increase in gait velocity in the APA group was paralleled by the results of the other measures of function and physical performance, for example, SPPB, Berg Balance Score, and the Motricity Index. We observed an opposite pattern in the control group, where gait velocity declined during the study period, along with the other measures of function and physical performance. The rapid rate of decline experienced by the control group in this 6-month study is worth noting. Moreover, the level of community participation measured with patient self-report using the SIS parallels the results obtained with the functional measures—increases in the intervention group and declines in the control group. These findings are consistent with the notion that functional limitations in patients with chronic disability are exacerbated by a sedentary lifestyle and that they can be reversed by participation in appropriately designed long-term, regular exercise programs.
The magnitude of change in gait velocity in this study was modest, but within the range of effects achieved by more intensive rehabilitation interventions (4-20 cm/s).44
These changes did have functional significance. Although the proportion of subjects classified as severely limited ambulators decreased from 45% to 25% in the APA group, this number increased from 29% to 42% in the control group.
Metabolic syndrome is a risk factor for adverse outcome in patients with cardiovascular disease. After myocardial infarction, patients with metabolic syndrome have a risk of major cardiovascular events of 2.6 times that of patients without the metabolic syndrome.45
Whether treatment of the metabolic syndrome with medications or drugs will lower this risk is unknown. However, it is interesting to note that the magnitude of the decline in insulin secretion with exercise observed in the current study is comparable with that observed with oral hypoglycemic agents.46
Sustained improvement in community activities with exercise training in stroke patients has been difficult to demonstrate. A recent meta-analysis18
found a medium-size effect of gait training on gait speed and walking distance for stroke patients, while cardiorespiratory and leg strengthening programs produced no effects. However, no convincing evidence of improvement in ADL or health-related quality of life was observed. Several characteristics of the trials included in the meta-analysis merit further scrutiny. First, only 1 study lasted 6 months, and another 19 weeks. All the remaining studies were from 4 to 12 weeks in duration. Second, only limited long-term follow-up of the subjects was attempted in these studies. Ada et al16
found that gains in walking speed, as compared with control, were maintained 3 months after cessation of their 4-week program, whereas in a more recent study of a 12-week exercise program, Mead et al47
found essentially no difference between treatment and control groups 4 months after the program ended. In another more recent study, Studenski et al48
found that a 12-week home exercise program significantly improved physical function and social participation as measured by the SF-36 and SIS, but these gains receded after 6 months. A randomized study of a treadmill aerobic exercise training intervention found a significant increase (17%) in absolute Vo2
peak. Similar findings were noted in measures of gait, with the treadmill-trained group improving 4-fold compared with the physical therapy–exercise control group32
; however, as with earlier studies, gains from the laboratory-based treadmill studies have not been demonstrated to translate into ongoing ambulatory activity in the home and community.
The improvements demonstrated on performance measures were not reflected in the BI (a measure of ADLs) or on the Index of Caregiver Stress. The known ceiling effects of the BI49
may have diminished the sensitivity to the APA intervention, but it is also likely that the improvements in balance and gait had only very limited impact on the majority of domains in the BI (feeding, bathing, grooming, dressing, bowel, bladder, toilet use, transfers, mobility, and stairs). Many of the caregivers for the participants enrolled in the APA study still provided transportation to the gymnasiums, so it may be that, from their point of view, the increases in mobility did not result in a striking increase in independence, either in performing ADLs or in requirements for transportation assistance. We were surprised that the SIS mobility scores did not achieve statistical significance between APA and control groups. The scores for this measure in the APA group had a very wide spread, and subjects were required to be able to perform the first 4 items to enter the study, thus introducing a substantial floor effect into this measurement.
Important Characteristics of the APA-Stroke Model
To promote fitness, enhance motor learning, disrupt patterns of learned nonuse, and optimize stroke mobility recovery, exercise behaviors must be integrated into everyday lives of stroke survivors. We believe the following characteristics of the APA-stroke model contribute to its success in this regard. First, the APA-stroke exercise intervention was specifically designed for stroke survivors, based on empirical evidence from previous research.32
Second, the group support demonstrated in the community-based APA-stroke program provided social support50
and may have contributed to improved self-efficacy and outcomes expectations.50-54
Participation was further reinforced by physician referral.55
It is also noteworthy that the local health authority worked closely with the gym instructors as part of chronic disease management. When a participant missed more than 3 consecutive classes or if the instructor observed something about a participant that raised concern, he or she was expected to contact the local health authority. The participant then received a telephone call from a physical therapist and, if appropriate, was referred to his or her physician or scheduled for a consultation with the rehabilitation service.
Community-Based Implementation of Exercise Programs for Stroke
A major barrier to participation in exercise programs for individuals with chronic stroke is the absence of accessible and appropriate exercise programs in the community. Prior to APA, efforts to implement evidence-based exercise interventions for people with chronic stroke in the community settings have not been widespread.14,15
APA-stroke was designed for implementation in community settings. It does not require costly equipment or room modifications and is taught by exercise professionals who have been hired by local gyms and received specialized APA-stroke instructor training. A major factor in sustainability and expansion of APA-stroke is that participants pay for the courses and cost is relatively low.
To the best of our knowledge, the Italian APA-stroke program is the largest of its kind in the world.56
After completion of the APA-stroke evaluation, the local health authority serving Empoli has continued to expand the program. From October 2005 to May 2008, the number of participants grew to 257 in 27 classes in 17 gyms, distributed in 11 out the 15 municipalities served by the local health authority. Because of differences in the financing of health services in Italy and other countries, community implementation of APA-stroke outside of Italy will require different organizational structures. For example, in the United States, new models that foster coordination between the health system (rehabilitation and physicians) and community-based organizations that offer exercise programs (such as Office on Aging Senior Centers, YMCAs, and private gyms) could provide a network of community-based APA-stroke programs with significant geographic access.
Previous research in an outpatient setting has demonstrated that stroke survivors with severe disabilities and comorbidities can safely accomplish exercise training using a treadmill equipped with a safety harness, and the exercise can induce positive functional and physiologic changes, even years following a stroke.32
The APA-study contributes new evidence that stroke survivors with appropriate medical screening can safely exercise in small groups in a community-based exercise program that includes an intervention specifically designed to improve ambulatory function. However, given the mixed results of previous exercise studies for stroke,19
and the vulnerability of the stroke population to falls,13
we recommend that any modification to this program be subjected to tests of safety and efficacy in a controlled setting before introduction to the community. Furthermore, ongoing monitoring to ensure that exercise protocols are being followed is important to safety as well as efficacy.57