Modified cardiac rehabilitation to enhance post-stroke physical and psychosocial function: does despression limit the response?

ABSTRACT Stroke has remained a leading cause of disability for the past thirty years and the number of people living with stroke and subsequent economic burden is expected to continue to grow over the next several decades. Chronic survivors of stroke have substantially reduced levels of aerobic and muscular fitness and, paradoxically, routine stroke rehabilitation is not delivered at an intensity sufficient to drastically augment aerobic and muscular capacities. Consequently, there is a critical need to develop comprehensive and appropriately dosed exercise programs that are scalable and complementary to current stroke rehabilitation practices. Cardiac rehabilitation is designed to enhance physical capacity via progressive exercise (aerobic and strengthening) and has been shown to improve physical and psychosocial impairments that are highly prevalent in patients following cardiac events (e.g., heart attack). Despite the cardiovascular origins of stroke, survivors are not eligible for cardiac rehabilitation programs. Consequently, survivors of stroke commonly experience a self-perpetuating cycle of reduced aerobic and muscular capacities, difficulties performing activities of daily living, and impaired psychosocial function. Experimental modified cardiac rehabilitation programs for stroke have utilized intensive aerobic exercise to improve aerobic capacity and locomotor function. Yet, despite representing at least one-third of survivors of stroke, those with post-stroke depression (PSD) have remained largely underrepresented in such programs. Given the negative effects of PSD on rehabilitation outcomes and the favorable effects of cardiac rehabilitation programs on physical function and depression, this represents an opportunity to improve our current approach to stroke rehabilitation. The proposed study directly addresses this gap in the literature by testing the effects of Physical Capacity training for ChroniC stroke – Building Aerobic capacity and Muscle Strength (PC3-BAMS), a 12-week modified cardiac rehabilitation program, on physical and psychosocial function in community-dwelling survivors of stroke with and without PSD. Subjects, with and without PSD, will receive 36 sessions of PC3-BAMS to determine the impact of a comprehensive modified cardiac rehabilitation program on post-stroke physical capacity and psychosocial function. Specifically, we hypothesize that subjects without PSD will demonstrate greater improvements in walking capacity as measured by the six-minute walk test and improvements in psychosocial function, as measured by the Stroke Impact Scale, will be associated with improvements in walking capacity. The results of this study will provide vital data describing the effects of a comprehensive modified cardiac rehabilitation program on improving physical and psychosocial function in survivors of stroke with and without PSD and will inform stakeholders and policymakers on the benefits of such programs. The findings from this study may help reduce the impact of chronic stroke and PSD on our public health system and improve the lives of the millions of survivors of stroke, their care partners, and families.