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.

Evidence from several studies consistently shows decline in cardiorespiratory (CR) fitness and physical function after disabling stroke. The broader implications of such a decline to general health may be partially understood through negative poststroke physiologic adaptations such as unilateral muscle fiber type shifts, impaired hemodynamic function, and decrements in systemic metabolic status. These physiologic changes also interrelate with reductions in activities of daily living (ADLs), community ambulation, and exercise tolerance, causing a perpetual cycle of worsening disability and deteriorating health. Fortunately, initial evidence suggests that stroke participants retain the capacity to adapt physiologically to an exercise training stimulus. However, despite this evidence, exercise as a therapeutic intervention continues to be clinically underutilized in the general stroke population. Far more research is needed to fully comprehend the consequences of and remedies for CR fitness impairments after stroke. The purpose of this brief review is to describe some of what is currently known about the physiological consequences of CR fitness decline after stroke. Additionally, there is an overview of the evidence supporting exercise interventions for improving CR fitness, and associated aspects of general health in this population.

Background and Purpose: Cardiovascular health is often impaired after stroke. Reduced exercise capacity ( O_2peak) and changes in the vascular system in the stroke-affected limb may impact performance of physical activities such as walking. There is little information regarding the role of prescribed moderate- to high-intensity exercise in subacute stroke. The purpose of this study was to examine whether an 8-week aerobic exercise intervention would improve cardiovascular health and physical performance in participants with subacute stroke. Methods: Ten subjects were enrolled in the study and 9 of them completed the intervention. Participants were aged 61.2 ± 4.7 years old, were 66.7 ± 41.5 days poststroke, and had minor motor performance deficits (Fugl-Meyer score, 100.3 ± 29.3). Outcome measures were taken at baseline, postintervention, and at 1-month follow-up. Brachial artery vasomotor reactivity (flow-mediated dilation [FMD]) of both arms was used to assess vascular health, and a peak exercise test was used to assess exercise capacity. The 6-minute walk test (6MWT) was used to assess physical performance. Participants exercised on a recumbent stepper 3 times per week for 8 weeks at a prescribed heart rate intensity. Results: At baseline, we identified between-limb differences in brachial artery FMD and low O_2peak values. After the intervention, significant improvements were observed in the FMD in both arms, resting systolic blood pressure, and the 6MWT. Although we also observed improvements in the resting diastolic blood pressure, heart rate, and O_2peak values, these changes were not significantly different. Discussion and Conclusion: Aerobic exercise in participants with subacute stroke was beneficial for improving cardiovascular health, reducing cardiac risk, and improving physical performance (6MWT). Video abstract available (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A29 ) for more insights from the authors.

Background: Assessment of peak oxygen consumption (V̇o2peak) using traditional modes of testing such as treadmill or cycle ergometer can be difficult in individuals with stroke due to balance deficits, gait impairments, or decreased coordination. Objective: The purpose of this study was to quantitatively assess the validity and feasibility of a modified exercise test using a total-body recumbent stepper (mTBRS-XT) in individuals after stroke. Design: A within-subject design, with a sample of convenience, was used. Participants: Eleven participants (7 male, 4 female) with a mean of 40.1 months (SD=32.7) after stroke, a mean age of 60.9 years (SD=12.0), and mild to severe lower-extremity Fugl-Myer test scores (range=13–34) completed the study. Methods: Participants performed 2 maximal-effort graded exercise tests on separate days using the mTBRS-XT and a cycle ergometer exercise protocol to assess cardiorespiratory fitness. Measurements of V̇o2peak and peak heart rate (peak HR) were obtained during both tests. Results: A strong relationship existed between the mTBRS-XT and the cycle ergometer exercise test for V̇o2peak and peak HR (r=.91 and .89, respectively). Mean V̇o2peak was significantly higher for the mTBRS-XT (16.6 mL×kg−1×min−1[SD=4.5]) compared with the cycle ergometer exercise protocol (15.4 mL×kg−1×min−1 [SD=4.5]). All participants performed the mTBRS-XT. One individual with severe stroke was unable to pedal the cycle ergometer. No significant adverse events occurred. Conclusion: The mTBRS-XT may be a safe, feasible, and valid exercise test to obtain measurements of V̇o2peak in people with stroke. Health care professionals may use the mTBRS-XT to prescribe aerobic exercise based on V̇o2peak values for individuals with mild to severe deficits after stroke.

Reduced middle cerebral artery blood velocity (MCAv) and flow pulsatility are contributors to age-related cerebrovascular disease pathogenesis. It is unknown whether the rate of changes in MCAv and flow pulsatility support the hypothesis of sex specific trajectories with aging. Therefore, we sought to characterize the rate of changes in MCAv and flow pulsatility across the adult lifespan in females and males as well as within specified age ranges. Participant characteristics, mean arterial pressure, end-tidal carbon dioxide, unilateral MCAv and flow pulsatility index (PI) were determined from study records compiled from three institutional sites. 524 participants (18-90 years; 319 females; 205 males) were included in the analysis. MCAv was significantly higher in females within the 2^nd (p <0.001), 5^th (p = 0.01), and 6^th (p <0.01) decades of life. Flow PI was significantly higher in females within the 2^nd decade of life (p <0.01). Rate of MCAv decline was significantly greater in females than males (-0.39 vs. -0.26 cm s^-1·yr, p = 0.04). Rate of flow PI rise was significantly greater in females than males (0.006 vs. 0.003 flow PI, p = 0.01). Rate of MCAv change was significantly greater in females than males in the 6^th decade of life (-1.44 vs. 0.13 cm s^-1·yr), p = 0.04). These findings indicate that sex significantly contributes to age-related differences in both MCAv and flow PI. Therefore, further investigation into cerebrovascular function within and between sexes is warranted to improve our understanding of the reported sex differences in cerebrovascular disease prevalence.