Exercise after stroke with Dr. Ada Tang

The Masters in Exercise podcast celebrates reaching 500 listeners with a discussion featuring Dr. Ada Tang, an associate professor at McMaster University, focusing on cardiovascular health in stroke patients. Dr. Tang shares her journey from physiotherapy to research, emphasizing the importance of exercise in stroke prevention and rehabilitation. The conversation explores exercise types and their benefits, the timing of post-stroke exercise, and barriers faced by patients and clinicians. Dr. Tang also discusses the limited evidence on exercise's impact on cognitive decline and the challenges of prescribing adequate exercise intensity in clinical settings.

• Dr. Ada Tang's interest in physical therapy began in high school with an anatomy course that fascinated her with the human body's structure.
• She initially intended to work in private practice in sports medicine but found her passion in hospital settings, specifically in stroke and geriatric rehabilitation.
• Her career in research started serendipitously while working in a teaching hospital, which rekindled her academic interests and led her to pursue a master's degree.
• Dr. Tang's research focuses on exercise in subacute stroke, a pioneering area at the time, which combined her interests in wellness and clinical practice.

"I was a physiotherapist for many years before I even went into research. I think when I was in high school and I was trying to decide what I wanted to do when I grew up, I took a course that actually we learned about the human body."

• Dr. Tang's interest in physical therapy was sparked by an anatomy course during high school, leading her to pursue a career in physiotherapy.

"I got into research because I was interested in trying it. It wasn't something that I wanted to do when I first graduated, but I was in a teaching hospital."

• Her entry into research was unplanned, driven by her environment in a teaching hospital that reignited her academic interests.

• Dr. Tang struggled with the decision to leave clinical practice for research but reconciled it by ensuring her research remained clinically focused.
• She values her clinical experience as foundational and strives to integrate it into her research endeavors.

"I really struggled because I missed clinical practice. When I left it, I was intending to go back, but then I knew that if I went on to do my PhD, that meant, well, I might not be able to go back."

• Dr. Tang faced a difficult decision between continuing clinical practice and pursuing a PhD, ultimately choosing research but maintaining a clinical focus.

"I hope that I still feel really grounded. All those years as I worked as a clinician, I think I reconciled it as, you know, if I'm going to continue on in research, then I want to make sure my research stays clinically focused."

• Her clinical experience remains a vital part of her identity, influencing her research to be grounded in practical, clinical applications.

• Current evidence does not conclusively show that exercise reduces the risk of recurrent stroke, but it can improve risk factors like blood pressure and cholesterol.
• Research has mostly focused on functional outcomes rather than direct prevention of stroke events.

"The evidence to date around exercise hasn't yet shown that we can reduce the risk of another stroke. We're getting closer to it. I think we all believe that it can, but none of the meta analyses have shown that it actually can reduce heart outcomes."

• While exercise is believed to reduce stroke risk, current evidence does not yet support this, focusing instead on improving risk factors.

"Only recently, I would say within the last two or three years, there's been meta analytic data that shows that we can improve risk factors so we can lower systolic blood pressure, we can improve HDL cholesterol, we can improve insulin levels."

• Recent meta-analyses indicate that exercise can improve metabolic and vascular risk factors associated with stroke.

• Aerobic exercise has been the primary focus of studies on post-stroke exercise, with less emphasis on resistance training.
• Mixed training programs often include functional movements rather than traditional strength training exercises.

"Most of the evidence has focused, I would say, on aerobic training, on aerobic exercise after stroke... there are studies that have looked at resistance training or strength training, but not as many."

• Aerobic training is the most studied form of exercise in stroke rehabilitation, with resistance training receiving less attention.

"I would still say though, that even the mixed training studies, the strengthening component of those studies haven't been necessarily like lifting weights, they've been more functional training."

• Mixed training programs typically incorporate functional movements rather than conventional weightlifting, reflecting a conservative approach to exercise prescription post-stroke.

• Resistance training for stroke patients is underexplored, with current practices being less intense and progressive than possible.
• There's a need to push the boundaries in resistance training to understand its full potential for stroke rehabilitation.
• Functional strength training using body weight and movement patterns is posited to be more translatable to functional recovery than traditional weight lifting exercises.

"We don't know what the potential for resistance training is for people with stroke. Just because I think that we haven't really pushed that far yet."

• The speaker acknowledges the unexplored potential of resistance training for stroke patients, indicating a need for further research and exploration.

"How translatable is that going to be to function? Whereas if I do more functionality strength training that uses body weight or in functional movement patterns, hopefully that will translate into function."

• Emphasizes the importance of functional strength training over traditional methods for improving practical outcomes in stroke rehabilitation.

• Exercise's impact on cognition in stroke patients is not as significant as in other populations, with mixed evidence on its benefits.
• Some studies show selective cognitive improvements post-exercise, but results are not consistent across all cognitive domains.
• Emerging research suggests potential sex differences in cognitive response to exercise, with females possibly benefiting more than males.

"We did not find that exercise training was effective in improving certain markers of cognition."

• Highlights the limited evidence supporting cognitive benefits of exercise in stroke patients, based on specific study findings.

"Females may respond to exercise in terms of improving cognition more so than males."

• Suggests potential sex-based differences in cognitive improvements from exercise, indicating an area for further research.

• Clinicians face barriers such as lack of time, equipment, and knowledge, affecting their ability to implement exercise programs.
• Exercise is often deprioritized in clinical settings due to competing demands and limited resources.
• Patients encounter barriers like access to services, transportation, and cost, which can hinder exercise participation.

"Clinicians feel that they don't have the knowledge or the skills to be able to provide exercise prescription or to screen or to test for exercise safety."

• Identifies a significant barrier for clinicians in implementing exercise programs, pointing to a need for enhanced training and resources.

"Exercise is not a priority. It just gets kind of shifted down the list when there's so many other things that are taking priority."

• Reflects the deprioritization of exercise in clinical practice due to other pressing demands, highlighting a systemic issue in rehabilitation settings.

• Efforts are being made to enhance PT curricula to better equip students with exercise prescription skills for diverse populations, including stroke patients.
• New graduates are expected to drive future changes in clinical practice, improving exercise implementation in rehabilitation.
• Ongoing research aims to bridge the gap between knowledge generation and practical application in clinical settings.

"At McMaster, we made a very conscious effort to try to increase the curriculum in our PT program to give the students knowledge about how to prescribe exercise safely."

• Describes initiatives to improve educational programs, ensuring future clinicians are better prepared to prescribe exercise.

"We know exercise is important. We need to also make sure it gets taken into practice."

• Stresses the importance of translating research findings into clinical practice to enhance rehabilitation outcomes.

• The optimal timing for initiating exercise post-stroke remains uncertain, with ongoing research exploring windows of opportunity for brain recovery.
• Theoretical frameworks are being developed to guide the timing of exercise interventions for maximizing recovery and brain plasticity.

"How early we can train these patients after a stroke. And there's been quite a lot of research."

• Acknowledges the complexity and ongoing debate regarding the timing of exercise initiation post-stroke, indicating a critical area for research.

• The timing of initiating rehabilitation after a stroke is debated; early mobilization may not always lead to better outcomes.
• The Avert trial indicated detrimental outcomes from very early mobilization within 24 hours post-stroke.
• Best practice guidelines suggest starting rehabilitation as soon as the patient is medically stable.
• It's crucial to monitor vitals during early mobilization to ensure patient safety.

"I think there's still a lot that we're learning and a balance that I think everyone's trying to strike between starting early and trying to capitalize on, you know, these critical time windows."

• The speaker highlights the ongoing research and the need to balance early intervention with patient safety.

"The Avert trial was... groundbreaking because they were pushing like, within 24 hours. Can we, can we mobilize early? And... they found... more detrimental outcomes in the very early group."

• The Avert trial is cited as evidence that very early mobilization might not be beneficial and can lead to negative outcomes.

• Current rehabilitation exercises often lack sufficient intensity to induce physiological changes.
• Studies show that only a small percentage of rehab sessions reach the target heart rate necessary for adaptations.
• Structured, sustained, and formalized exercise programs are needed to achieve cardiovascular and aerobic adaptations.

"The exercise that is prescribed for these patients doesn't reach intensity, which is needed to create changes."

• The speaker points out a critical issue in rehabilitation: the lack of intensity in prescribed exercises.

"It needs to be structured, it needs to be formalized, and it needs to be sustained for a period of time and at certain minimum intensities."

• Emphasizes the need for structured and sustained exercise programs to achieve desired health outcomes.

• Changes are needed at the clinical, educational, and logistical levels to enhance exercise intensity.
• Increased staffing, better equipment, and dedicated time for exercise classes are essential.
• Engaging hospital administrators and clinicians in resource allocation is crucial for implementing changes.

"Changes need to happen at the clinical level, but also in terms of the education of the patient... and logistics to be able to have the equipment or the resources."

• Highlights the multifaceted approach required to improve exercise intensity in rehabilitation.

"What do they think about... engaging them to talk to them, say, you know, I think this is worth our time and our resources to dedicate the gym space."

• Discusses the importance of involving hospital administrators in the decision-making process to allocate resources effectively.

• Graded exercise tests can improve safety but may not be feasible in all settings due to lack of resources.
• Submaximal exercise testing can be an alternative to assess exercise safety and intensity parameters.
• Collaboration with cardiac rehab facilities can help provide necessary testing for stroke patients.

"Do you think that these tests are mandatory? Do you think they are a must or you think that it can be a barrier if you make them mandatory?"

• Raises the question of whether mandatory graded exercise tests are feasible or if they pose a barrier to rehabilitation.

"Different therapists I've talked to... they've tried to partner with their cardiac rehab colleagues to say, could we send our patients, our stroke patients to your exercise lab for testing."

• Suggests collaboration with cardiac rehab facilities as a practical solution for conducting necessary exercise tests.

• Emphasizes the importance of ongoing education and skill development in the medical field.
• Highlights that knowledge acquisition is not a one-time event but requires dedication and consistency.

"You have to kind of keep it up."

• Continuous learning is essential for maintaining competency and effectiveness in one's professional role.

• Discusses the importance of assessing patient risk before recommending exercise, especially for those with high-risk conditions.
• Notes that risk is dynamic and can change based on health status and physical activity levels.
• Encourages minimizing barriers to exercise by reducing unnecessary medical clearances for lower-risk individuals.

"Risk isn't an absolute thing that doesn't change and is static. Right. Risk is fluid and dynamic."

• Risk assessment should consider individual health status and exercise history to encourage safe physical activity.

• Describes the revised American College of Sports Medicine (ACSM) guidelines for exercise screening.
• The primary screening question now focuses on whether an individual exercises regularly, rather than past medical events.

"Habitual physical activity is your first pass at streaming someone into whether there should be high or low risk."

• Regular physical activity is a crucial factor in determining exercise risk level, reflecting a shift in screening priorities.

• Introduces arterial stiffness as a novel risk marker for cardiovascular disease.
• Explains how arterial stiffness can indicate plaque deposition and impaired vascular function.
• Describes the non-invasive measurement of arterial stiffness using pulse wave velocity.

"The faster the pulse waves travel, the stiffer the arteries are."

• Arterial stiffness measurement can provide early detection of cardiovascular risk, aiding in preventive healthcare.

• Reflects on the speaker's career journey and the importance of embracing challenges and opportunities.
• Stresses the value of being open to learning and adapting to new roles and experiences.

"I try to be open to opportunities. I try to just embrace things as they come."

• Personal growth and career advancement often come from stepping outside of one's comfort zone and seizing new opportunities.

• Defines success as helping others improve, both in therapy and research settings.
• Personal and professional success is linked to overcoming challenges and contributing positively to others' lives.

"When I see projects come to fruition, when I see my students who are doing amazing work, that's, for me, really, really rewarding."

• Success is measured by the impact on others and the fulfillment derived from meeting challenges and achieving goals.