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It is estimated that up to 75% of stroke patients admitted to an inpatient rehabilitation unit will suffer some medical complication(s). Approximately 20% of stroke patients in general re-enter acute care due to medical complications of stroke, mostly of a cardiopulmonary nature. It is thought that the hospitalization rates for other complications remain low because the nature of rehabilitation programs is to teach the patient to improve function and compensate for deficits all of which related to prevention or early identification of medical complications.

Cardiovascular Complications

Cardiovascular complications occur in 40-75% of stroke survivors. They include:

• Hypertension
• Angina
• Heart attack
• Heart arrhythmia
• Congestive heart failure

Some of these complications may be related to prolonged bed rest and minimal mobility, and some may be related to the general older age of the stroke population. In addition, the presence of hemiparesis can increase the demands on the cardiovascular system during physical activities. Evaluation of cardiovascular disease may be difficult due to cognitive impairment of the patient which interferes with recognition and reporting of symptoms and previous medical history. It is important that all medications prescribed for the treatment of complications be coordinated by a health professional since some drugs may interact with those being used to control other comorbid conditions.

Cardiac and Neuromuscular Deconditioning

Deconditioning refers to the general physiologic effects of prolonged immobility experienced by many stroke patients which is an increased burden on the cardiovascular and neuromuscular systems of the stroke survivor. Deconditioning plays an important role in the overall functional status of a stroke patient as it impacts the intensity of physical training and effort he/she will be able to tolerate during rehabilitation. Preventing or reversing deconditioning has a strong impact on the physical status of stroke survivors.

There are many ramifications for the stroke patient associated with deconditioning including:

• Increased heart rate at rest
• Increased heart rate with minimal exercise
• Reduced aerobic fitness
• Reduced levels of maximal oxygen uptake (VO2max) during exercise
• Angina in patients with previous coronary disease
• Changes to the reflexes that prevent the ability to maintain an upright posture (orthostasis)

Deconditioning can occur within 3 days of immobilization and is more severe in elderly patients. The key to reversing deconditioning is to avoid prolonged bed rest and immobility by progressive steps starting with helping patients sit up on the bed or in a chair, exercise (regular or isometric) while laying down, and helping patients stand upright as soon as it is safe to do so. If the patient shows signs of mild deconditioning, treatment may consist of progressively increasing the sitting time in a chair; for more severe deconditioning or orthostatic hypotension, treatment may consist of using a tilt-table where the patient is secured to a table that can then be progressively tilted in varying degrees towards the standing position.

Some studies have shown that aerobic exercise is beneficial for reversing chronic cardiac deconditioning. Poor physical fitness is a risk factor for stroke so it is not surprising that many stroke patients have reduced peak oxygen consumption (aerobic capacity) and poor endurance for physical activity. Low aerobic fitness is also associated with cardiopulmonary disease in general and osteoporosis. The physical limitations of the stroke patient exacerbate the already low levels of aerobic capacity and therefore need to be addressed in rehabilitation. A literature review of aerobic exercise among stroke patients showed that aerobic exercise training 3-5 days a week for 20-40 minutes is beneficial for the improvement of aerobic capacity at the end of the training period (12-14 weeks). This applies to patients with mild or moderate impairment who have low-risk of cardiovascular complications from exercise training. Equipment used in the study included exercise on a cycle ergometer, treadmill; functional activities such as brisk stepping; and water based activities. Any improvement in aerobic capacity also positively impacts tolerance for other physical training and activities of daily living.