Question

Mr. JS is a 69 yr old male with a history of obesity, type 2 diabetes, and hypertension. He is 3 mo poststroke and has gone through basic physical therapy. He has right-side hemiplegia, speech impediment, and depression. His resting BP is 150/90.

Medications: Ticlopidine, hydrochlorothiazide, and glucophage.

Mr. JS reported to his physician with numbness, dizziness, motor function impairment on the right side of his body, and vision problems. The patient was referred, and stroke was confirmed and diagnosed by MRI.

Objective and Laboratory Data Exercise Test Results The patient achieved 6 METs on a progressive cycle ergometer test to exhaustion with no significant ECG changes. Peak HR was 140, and peak BP was 210/100.

Assessment and Plan Exercise Prescription Mr. JS was prescribed aerobic exercise 3 d per week, progressing up to 5 d per week, and resistance exercises 3 d per week. The initial intensity for aerobic exercise was set at 40% to 50% heart rate reserve and a 12 to 15 rating of perceived exertion on the Borg scale, progressing every 3 wk as tolerated with a goal of 80% to 85% of heart rate reserve for at least two of the training sessions per week. The resistance exercises were to be performed as tolerated for 10 to 15 repetitions.

Initial duration for the aerobic exercise was 15 min, progressing every 3 wk as tolerated up to 1 h per session. For higher-intensity sessions, duration should be reduced to 30 min. Resistance exercises were to start with one set of exercises for 3 wk, progressing up to three sets. The initial mode of training was a mix of water-based aerobic exercises and supported treadmill exercises. Support in the latter is preferably in the form of handrails, but a support device can be used if it enhances patient comfort. These modes serve to increase cardiorespiratory fitness and other factors related to walking performance such as balance and muscular strength. As frequency and duration progress, cycle ergometry exercise can be added. The patient’s ability to perform resistance exercises with elastic bands and available strength training equipment should be evaluated. Initial exercises may need to include several movements against gravity and assisted movements.

Because of comorbid conditions (diabetes, obesity, depression), the lower end of the ACSM-recommended range for intensity and duration should be used initially. But because caloric expenditure and improved insulin sensitivity are secondary goals, frequency should progress to the upper end of the ACSM-recommended range. A variety of modes should be employed to enhance patient interest, an important consideration because of depression. Tests for V̇O2peak should be repeated, and the testing battery should include at least two functional tests (e.g., 40 m walk speed, 6 min walk, Timed Up and Go, chair stands) so that the patient and the clinician can progress ambulation. To assess progress for body fat percentage and weight, an estimate of body fat percentage (skinfolds, girths, or impedance) can be used. Because Mr. JS exhibits characteristics of metabolic syndrome, waist-to-hip ratio should be determined regularly.

Case Study Discussion Questions 1. What are the main factors that determine the mode of training (type of exercises you would prescribe) in this patient population?

2. What common associated conditions (e.g., obesity, diabetes, hypertension) may alter the exercise prescription for stroke patients?

3. What are the factors that determine the type of assessments performed? How would you do exercise prescription in this situation?

4. What exercise prescription would you give Mr. JS?

5. What other questions are important to ask Mr. JS when designing an exercise prescription?

Answer 1

Answer-1 the main factors to keep in mind when prescribe the exercise are the physical condition of the patient. The respiratory condition and weakness or firmness of the grip. All the physical and psychological condition of patient are important.

Answer-2 the other physical condition include the fatty content of the body. Movement of the limbs and the other posture making ease and difficulty.

Answer-3 the factor for assessment include the physical and psychological condition of the patient. in such case only light exercise can be prescribed which consist walking, jogging and light body movements.

Answer-4 in this case the resist exercise should not be performed. Only light exercises like jogging, walking, dance in a low pace and light exercise for belly fat should be performed and there should be increase in repetition with a increase in comfort.

Answer-5 other questions that should be asked are the pain of the limbs and problem in movement.