Strength Training, Gait Performance, and Stroke Survivors

A patient working on his gait performance.

With this growing special population of stroke survivors, the allied health community is striving to help restore something that has been lost. Hemiparesis is one of the many side effects that stroke survivors may experience. It causes motor control impairment, to some degree, that is a result of weakness or the inability to move one side of the body.3 Depending on the severity of the survivor’s case, it can make it difficult to perform daily tasks such as holding or grasping things, reaching above their shoulder, extending their arm, stepping up or down, and even walking on flat surfaces. Regaining the motor function to perform these daily tasks should be a goal for every stroke survivor. One aspect in particular of hemiparesis is that gait performance varies depending on the severity of the hemiplegia. However, studies have shown gait performance can be improved through strength training.

According to Cramp et al., strength of the hip flexor, knee extensor, and ankle plantarflexor muscles have been shown to have a moderate to strong correlation with gait velocity.2  Studies have shown that strength of the muscle groups have been significantly improved in stroke survivors after strength training programs.1,2 Therefore, it is valid to assume that lower limb strength training should be included in exercise training for stroke survivors with hemiplegia. If muscular strength improves, it is quite possible that the gait velocity will improve as a result.

In a study conducted by Cramp et al., a significant increase in muscular strength in the paretic limb was seen from the baseline to after eight training sessions and continued to increase with more training sessions.2 They observed that both the muscular strength of the knee extensors and the gait velocity increased significantly.2 Badics et al. found that muscular strength increased significantly in all patients and this increase was positively correlated with the intensity and number of exercising sessions.1

Several studies have highlighted the benefits and improvements from strength training for stroke survivors suffering from hemiplegia, but are there any negative side effects? In a study by Badics et al. that had 56 patients, no negative side effects on muscle tone, or complications such as joint pain were found.1 In fact, it is even reported that some patients, despite having years between their stroke event and the training program, improved muscle strength and gained empowerment for activities of daily living.1

Interested in learning more about current exercise prescriptions for stroke survivors? Check out my blog here.

1 Badics, E., Wittmann, A., Rupp, M., Stabuer, B., & Zifko, U. (2002). Systematic muscle building exercises in the rehabilitation of stroke patients. NeuroRehabilitation, 17(3), 211-214.

2 Cramp, M., Greenwood, R., Gill, M., Rothwell, J., & Scott, O. (2006). Low intensity strength training for ambulatory stroke patients. Disability & Rehabilitation, 28(13-14), 883-889.

3 Effects of stroke. (2012). Retrieved September 14, 2014, from http://www.stroke.org/site/PageServer?pagename=effects

What Exercises Are Safe During Pregnancy?

Over the years, pregnant women have come to learn that not only is exercise during pregnancy allowed, but it is highly recommended. The American College of Obstetricians and Gynecologists (ACOG) recommends that pregnant women accumulate 30 minutes of moderate-intensity exercise on all or most days of the week once cleared by your physician to exercise.1

Ok, I am cleared, now how should I exercise?

Exercising at a moderate intensity has shown to be the most beneficial. This intensity can be measured in several ways. An exercise heart rate of 135-150 bpm for women 20-29 years and 130-145 bpm for women 30-39 years is recommended.1 Another way to measure how hard you are working is with an RPE Chart. On a scale of 6-20, you should find yourself working between a 12-14. Lastly, it is important to be able to maintain a conversation while exercising. If you are not able to talk effectively, you may be working too hard.

What specific exercises can I do?

Exercises should be dynamic and involve the large muscles of the entire body. Walking and cycling are great cardiovascular exercises that work the entire body. Water aerobics is another great way to stay in shape while eliminating the extra weight gained during pregnancy. Resistance training is also beneficial, especially for those who trained before pregnancy. However, increased repetitions with less weight is advised rather than low repetitions with maximal weight (weight produces muscular fatigue within 12 to 15 repetitions)1. Prenatal yoga is a great way to keep the body flexible and relaxed during pregnancy and has been shown to relieve some back pain caused by weight gain.

What exercises should I avoid?

Any activities that may harm the fetus such as contact sports (hockey, basketball, soccer) should be avoided. Activities that are high risk in falling (horseback riding, skiing, gymnastics) should also be avoided. It is also important to refrain from exercises that are performed from a supine position, especially after the first trimester. Lastly, the Valsalva maneuver (holding one’s breath while exerting) should be avoided.

1American College of Sports Medicine. (2013). Exercise Programming Across the Lifespan:

Children and Adolescents, Pregnant Women, and Older Adults. In ACSM's Resources for the Health Fitness Specialist (pp. 220-221). Lippincott Williams & Wilkins.

Pomerance Bell, R. (2013, November 28). Yes, You Can-and Should- Exercise During

Pregnancy. Retrieved September 14, 2014, from http://health.usnews.com/health-news/health-wellness/articles/2013/11/28/yes-you-can--and-should--exercise-during-pregnancy?page=1

Ambulation in Stroke Patients with the Biodex Unweighing System and Gait Trainer

Stroke is known as the silent killer, killing someone in America every four minutes. It is the most common cause of death, second only to heart disease. “Stroke is a leading cause of serious, long-term disability in the United States (Survey of Income and Program Participation [SIPP], a survey of the US Bureau of the Census).” 2  Following cerebrovascular accident, one of the main impairments is reduced muscle strength. 1 This is one of the primary reasons for activity limitations related to mobility in stroke victims, and has been shown in several studies to greatly affect the measures of walking gait performance. “Walking is among the most important domains of the activities and participation components in International Classification of Functioning, Disability and Health (ICF) core set for stroke.” 2 Therefore, walking should be a main function of stroke rehabilitation in order to optimize the recovery of muscle function and to regain ambulatory ability. However, due to tremendous lack of mobility combined with a sedentary lifestyle, this is generally not a simple task and may require some specialized methods of rehabilitation. 

The Biodex is an assistive treadmill with the capability to un-weigh individuals with a support harness and assesses their gait and stride length automatically. It will also support up 40% of the individuals total body weight reducing the load on the body, especially lower extremities, during ambulation. The Gait Trainer feature of the Biodex provides visual and auditory feedback on an instrumented deck in real time to prompt the individual into a correct gait pattern. Step length, step speed and right-to-left time placement are crucial aspects; patient footfall is compared to desired footfall step after step, both on the display in real time and documented on a histogram.

One of the many benefits that the Biodex system provides for individuals recovering from stroke, is the ability to extract and retain nominal data on the ability to walk functionally and the amount of stress placed on each side of the body.  

During assessment the gait trainer records movement and will provide verbal instruction on how to correct gait distance and foot placement. With absolutely no fear of falling due to harness suspension, individuals are able to build extreme confidence and control by walking with a normal stride and arm-swing pattern. For many individuals following post-stroke sequelae, walking patterns are not nearly as natural or balanced as they were pre-stroke. The data retained from the Gait Trainer allows individuals to understand the severity of the limitations produced by stroke as well as program exercise and set rational personal goals that can be assessed and tested.

The Biodex-Weight Support Treadmill and Unweighing system broadens the ability of training and rehabilitation for stroke survivors through enhanced self awareness and self-confidence.        

1 Flansbjer, U., Downham, D., & Lexell, J. (2006). Knee Muscle Strength, Gait Performance, and

Perceived Participation After Stroke. Archives of Physical Medicine and Rehabilitation, 87(7), 974-980. Retrieved September 13, 2014. http://www.archives-pmr.org/article/S0003-9993(06)00286-3/fulltext

2 Jones, D. (2010, January 1). Heart Disease and Stroke Statistics—2010 Update A Report From the

American Heart Association. Retrieved September 13, 2014, from

http://circ.ahajournals.org/content/121/7/e46.full

3 Wilcox, D., Boyd, K., Feeley, J., Packel, A., & Rosenberg, E. (2012, January 1). A Clinical Guideline

for the Treatment of Patients with Neurological Conditions using Biodex Unweighing System and Gait Trainer. Retrieved September 14, 2014, from http://www.biodex.com/sites/default/files/documents/clinical_guideline_neuro_conditions_14225.pdf

Exercise and Nutrition Myth Busters: Late Night Snacks = Fat Increase

 A popular myth is one of the bedtime snack. Alarm bells ring when someone refers to the stigma of eating one last thing before they head to bed. This is because those snacks are usually a person caving in to sugary cravings like ice cream, or telling themselves they need to soak up that excess alcohol in their system with some late night French fries. However, late night meals do not necessarily have to be harmful, they can actually be a great addition to your nutrient timing to help muscle recovery, increase cortisol extraction from the body, and help you sleep.

Most people have been told that eating late at night will lead to indigestion which, in turn, will lead to interrupted sleep patterns. According to Stephanie Maxson, senior dietician at the University of Texas’ MD Anderson Cancer Center, a decrease in blood sugar after not ingesting food for hours before bed and then sleeping will cause you to wake up in the middle of the night and cause you to feel sluggish in the morning.2 This is primarily due to insulin sensitivity.

John Ivy, PHD in Kinesiology at the University of Texas, has overseen research which has mainly focused on the acute and chronic effects of exercise on metabolism. Currently, “he is focusing on the cause of muscle insulin resistance.”1 In his book, Nutrient Timing, he discusses insulin sensitivity and how keeping it high is key. Insulin’s job is to keep blood sugar levels from rising too high, and when you intake a carbohydrate (i.e.honey), “your body releases insulin to regulate and maintain homeostasis.”1 If insulin’s sensitivity is not kept high due to nutrient intervention then this will affect the body’s ability to uptake amino acids which help build muscle.3 However, John Ivy doesn’t want you to go down a bottle of honey before you go to bed, because that will increase the body’s ability to store fat. John Ivy says that in order to avoid a major insulin spike (remember, we want homeostasis) during the night, you need something that increases sensitivity (carb) but digests slowly as well (protein).3 If this happens, insulin will remain slightly elevated and blood cortisol (stress related fat storing hormone) will be lowered. So what should you eat?

The best thing to eat, according to John Ivy, is to eat a carbohydrate/protein combination that has a 2:1 ratio. You could eat some low fat Greek yogurt with some fruit, or a turkey sandwich. While a protein shake might be simpler to make and easier to ingest, “they tend to have fast-digesting protein and high-glycemic carbohydrates which are absorbed more quickly than whole food.”3 A liquid carb/protein drink might be fully absorbed within thirty to sixty minutes, whereas a solid food snack may take two to three hours to digest,” which is ideal.3

So if you are starving before going to bed or are on an exercise regimen which involves building and keeping muscle while decreasing fat, have a small protein and carbohydrate snack (1:2 ratio) that will increase that insulin sensitivity and not allow it to spike. However, don’t be tempted by those high-glycemic foods like PIZZA! You will be full, for a little while, but a little fatter in the morning with a lot of indigestion interrupting your sleep cycle.

1 Gastelu, D., & Hatfield, F. (2013). Appendix. In Sports Nutrition (Third ed., p. 336).

Carpinteria, CA 93013: International Sports Sciences Association.

2)  Heid, M. (2014, July 23). You asked: Will eating before bed make me fat? Retrieved

September 14, 2014, from

http://time.com/3020266/you-asked-will-eating-before-bed-make-me-fat/

3 Ivy, J., & Portman, R. (2004). Nutrient timing: The future of sports nutrition. Laguna Beach,

CA: Basic Health Publications.

Exercise Lies: Running for Hours = Fat Loss

Over the past few years, one of the most common mistakes by fitness seeking individuals is that running for hours will result in weight loss. This common mistake is often made by people wanting to get fit and achieve their goal of losing body fat percentage. They believe that running for miles upon miles for hours on a treadmill or track will help them achieve this goal. These people will then get frustrated when they lose a little weight, but their percent body fat has not changed. Why is this?

Aerobic energy systems are activated when a person exercises for low to moderate intensity (40-75% of VO₂ Max) for a duration of 60 seconds to 3 hours. During this aerobic exercise oxygen is synthesized and hormones such as cortisol and testosterone are produced the concentration of these hormones is determined by the intensity and duration of the exercise. Cortisol is a hormonal response to stress on the body, which helps to increase the concentration of glucose in our blood so it is a readily available energy system for muscles to utilize. Cortisol can be a good thing, but only when released infrequently and for short periods so that it can help with the body’s threat to internal imbalance. However, if a person is exposed to cortisol for a long period of time (30 minutes or more) under a stressful act, such as running, they may experience long-term consequences.

When over-exposure of cortisol is seen in long durations of exercise, it may overtake the levels of testosterone in the body. Cortisol is associated with breakdown of muscle tissue, while testosterone is associated with building muscle. When cortisol is produced at such a high level for such a long time, it is very hard to flush out of the body’s system. When the ratio of testosterone and cortisol is unfavorable (e.g. T < C), muscle is lost. When muscle, which helps to burn fat, is lost fat percentage is increased. It has been found that there was no increase in cortisol after 10 minutes of aerobic exercise (75% of VO₂ Max) in 17 male physical education students but increased by 54 percent compared to their pre exercise levels.1 This demonstrated cortisol was influenced by prolonged intense exercise. In another study conducted in 201, 42% of analyzed cortisol levels in 304 amateur endurance athletes had an average additional secretion above the control (as seen in the graph below).2  Which means, that of those athletes running for 30 minutes or more, cortisol amounts doubled which could lead to a very high ability for the body to store fat in the future, for more running. It is a vicious cycle. All one has to do is compare archetypes of sprinters to marathon runners (see above).

As for alternatives to the myth of running for fat loss, simply walk. Walking for 40% of VO₂ Max for 1 hour actually lowers Cortisol levels. This occurs because the intensity is lower, and the cortisol has had a chance to be removed from the body’s system faster than it can be secreted. If you still miss the heart pounding excitement that you get from running, try high intensity intervals such as 1 to 16 seconds of sprinting then equal or more time walking for removal of Cortisol. This type of training may actually stimulate muscle growth at the same time.

So if you are a person with the goal of fat loss, but just don’t have the time to commit to hours and hours of running, GOOD NEWS, you should not do it anyway. Commit to slow walking for 45 minutes to an hour, or a few intervals of sprinting, and you will be on your way to fat loss without the threat of cortisol.

1Kindermann, W., Schnabel, A., Schmitt, W., Biro, G., Cassens, J., & Weber, F. (1982).

Catecholamines, growth, hormone, cortisol, insulin, and sex hormones in anaerboic and aerobic exercise. European Journal of Applied Physiology and Occupational Physiology, 49(3), 389-399.

2Skoluda, N., Dettenborn, L., Stalder T., & Kirschbaum C. (2011). Elevated hair cortisol  

concentrations in endurance athletes. International Journal of Psychoneuroendocrinology, 37(5), 611-7.

Practice What You Preach?

As a graduate student in the Kinesiology department and Clinical Exercise Research Facility, teaching assistant for the Kinesiology department, and a graduate assistant coach for the cross country and track and field teams, I have many roles at Tarleton State University.  Every single one of these roles comes with the expectation that I am a role model and that I lead by example.  When I was hired to do these jobs I had tests to take and papers to sign stating that I understood what my expectations were as an employee and a representative of Tarleton State University.

One of the classes that I teach in Kinesiology is called Conditioning and Fitness.  In this class, undergraduate kinesiology majors are required to take multiple health-related fitness tests and are graded upon how they fair against the American College of Sports Medicine’s norm-referenced standards. According to the ACSM, “tests should yield results that are indicative of the current state of physical fitness, reflect positive changes in health status from participation in a physical activity or exercise intervention, and be directly comparable to normative data.”1 I am proud of the fact that at Tarleton we are investing in more than our students academic success. By requiring kinesiology majors to pass a physical fitness test before they can graduate helps the students to invest in themselves and apply what they are learning in our department.  

The definition of role model is defined as “a person whose behavior in a particular role is imitated by others.”2 How important is it for coaches, personal trainers, kinesiology instructors, etc., to practice what they preach, if at all?  Is there any credibility lost with a “do as I say and not as I do” approach?  I believe credibility is lost. I would not be convinced to hire a personal trainer at the gym if they did not look like they worked out themselves.  I am not suggesting that every kinesiology major be capable of competing at the Olympic games, but I do feel that there is a certain level of fitness that needs to be maintained.  I know that this can be a very gray area and is not as black and white as it seems. What are your thoughts on the issue?

1. Pescatello, L. (2014). Health-Related Physical Fitness Testing and Interpretation. In ACSM's guidelines for exercise testing and prescription (9th ed., p. 61). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health.

2. "Role Model." Merriam-Webster.com. Merriam-Webster, n.d. Web. 11 Sept. 2014. <http://www.merriam-webster.com/dictionary/role model>

The Benefits of Exercise on Stroke Victims

For the general population, exercise provides numerous physical, mental, and social health benefits such as reduced risk of secondary diseases, improved mental clarity, reduced stress levels, and enjoyment.The same can be said for individuals with paralysis caused from cerebrovascular accident (stroke). Stroke can cause neurologic dysfunction as well as neuromuscular paralysis, leading to frozen muscles and joints, muscular atrophy, and even secondary atherosclerosis. The severity and bodily functions affected in stroke survivors differ from case to case, however these individuals can all benefit from exercise, whether traditional or modified. In fact, they  seek to reap not only the same health benefits as the general population, but additional benefits that exercise provides for those with paralysis.

In a study comparing the … it was concluded that “regular physical activity may be a decisive factor for the well-being of paraplegics.”1. Likewise, a study investigating the … identified improved general health, better fitness and fortitude, and better physiological and mental well being as the most reported positive effects of exercise among people with physical disabilities. In addition, for those who have a lower degree of participation, exercise could have a double effect on their health. Among popular exercises for individuals with disabilities the most popular included strength training, aquatic training, and horseback riding.

In spite of the evidence supporting the benefits of exercise, it can be difficult for paralyzed individuals to locate and join an exercise facility willing to work with the limitations and risk factors of their condition. Tarleton State University houses one of the only University funded exercise facilities for individuals with disabilities specializing in paralysis. This facility is known as the Tarleton Laboratory for Wellness and Motor Behavior, and was formed in the early 1990’s to benefit individuals with disabilities through adaptive exercise and is free of charge. The Laboratory is supervised by two kinesiology graduate students who are responsible for programming exercises and scheduling intern and teacher assistant kinesiology undergraduate students. All students are handpicked for their excellence and expertise in the classroom, as well as their passion to help individuals with disabilities such as stroke. Through adaptive forms of exercise the Laboratory for Wellness and Motor Behavior improves individuals total quality of life through corrective human movement and increased physical activity.  

It is crucial to understand the logical phrase “if you don’t use it, you lose it” and how it applies to a sedentary lifestyle experienced by individuals living with paralysis.  

Resources

1Grange, C. C., Bougenot, M. P., Groslambert, A., Tordi, N., & Rouillon, J. D. (2002). Perceived exertion and rehabilitation with wheelchair ergometer: Comparison between patients with spinal cord injury and healthy subjects. Spinal cord, 40, 513- 518. Retrieved from http://ehis.ebscohost.com.zeus.tarleton.edu:81/eds/pdfviewer/pdfviewer?sid=86a53182-3a05-49ae-8fdd-3ab654bf05a0%40sessionmgr15&vid=5&hid=8

2Junker, L., & Carlberg, E. B. (2011). Factors that affect exercise participation among people with physical disabilities. Advances in Physiotherapy, 13, 18-25. Retrieved from http://ehis.ebscohost.com.zeus.tarleton.edu:81/eds/pdfviewer/pdfviewer?sid=86a53182-3a05-49ae-8fdd-3ab654bf05a0%40sessionmgr15&vid=3&hid=8  

Personal Training : Professional and Personal Relations

As a personal trainer and someone who works alongside personal trainers,it has been found that the job of training people to be in better physical health becomes more than sets, reps, and intervals. Clients begin to see trainers as friends and people who are in their support group. Just like coaching, personal training is difficult without a level of trust, communication, and accountability. As time goes on, and a relationship builds between the client and trainer, they almost can’t resist talking about their job, family, and personal problems going on in their lives. The client feels a sense of trust  from the time spent together and not to mention the fact that they have opened up about their self image and bodily insecurities. 1When clients begin to vent about work or whatever stresses they have, trainers listen to them because they feel their job is to help alleviate stress through exercise and release endorphins, the brain’s feel-good neurotransmitters.

2The issue that comes up with letting clients, who are mostly females, vent and confide in their trainers, who are mostly males, is getting too close or involved with clients. Trainers should stay away from giving input or speaking on relationship problems clients bring up and keep the relationship professional and not put themselves in the middle of the clients personal relationships. 3 This instance can happen both ways when trainers try to get involved with clients outside of work or try to trade off sessions for dates with a client, which is unprofessional and can potentially lose clientele and create a bad reputation for that trainer. What the trainer should do is avoid the situation if it gets too personal and if it continues to be brought up, communicate with the client about keeping the relationship professional. Clients should be reminded that the trainer’s  job is to support fitness goals and help in any way possible with nutrition and workouts to help them achieve those goals.

References

1. Exercise and stress: Get moving to manage stress. (2012, July 21). Retrieved September 7, 2014, from http://www.mayoclinic.org/healthy-living/stress-management/in-depth/exercise-and-stress/art-20044469

2.Personal Trainer Salary Statistics as of 2013. (2013, January 1). Retrieved September 7, 2014, from http://jobstat.net/jobs/personal-trainer/

3.CONFESSORE, N. (2005, April 14). When a Personal Trainer Gets Too Personal. Retrieved September 7, 2014, from http://query.nytimes.com/gst/fullpage.html?res=9C00E0DC133EF937A25757C0A9639C8B63