High-intensity interval training (HIIT) after stroke: a big hit?

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Swiss Junior Doctors and Undergraduate Perspective on Sport and Exercise Medicine Blog Series

By Michiel R.M. Twiss @physiotwiss

Stroke and ischemic heart disease accounted for 15 million out of 57 million deaths in 2016; these cardiovascular diseases have been the leading causes of death for the last 15 years [1]. Stroke incidence is proportionally related to age – the average population is aging – so stroke prevention and treatment is increasingly important. Classic neurorehabilitation programmes for stroke survivors provide a ‘limited opportunity for cardiovascular exercise’ and ‘the use of moderate-intensity continuous exercise (MICE) to improve cardiorespiratory fitness. Niether of these two types or exercise is routinely implemented in clinical practice. When used, their intensity may be insufficient to elicit a training effect [2]. Post stroke guidelines recommend MICE to improve aerobic capacity, mobility and walking speed. However, effects on functional recovery, aerobic fitness and quality of life remain unclear [3]. Most stroke rehabilitation programs – which generally last only a few months – lack aerobic exercise training [4]. This might be due to lack of knowledge regarding exercise testing and prescription for people after stroke. Classic stroke rehabilitation certainly does not include aerobic- or resistance-type high-intensity interval training (HIIT). One assumption is that high-exertion activity would increase spasticity [3]. HIIT is a training that consists of repeated (very) short bursts of high-intensity exercises (at 85%-95% of peak heart rate) followed by low-intensity recovery activity. HIIT improves fitness, ie, aerobic capacity in healthy as well as persons with cardiovascular diseases [4]. Does HIIT constitute a safe and effective method to improve the lives of stroke survivors? What does science tell us?

What type of (research) knowledge exists regarding HIIT in stroke survivors?

HIIT for stroke survivors undoubtedly found its way into neurorehabilitation after many benefits were shown over the years ‘High-intensity interval training (HIIT) emerged as a powerful time-efficient alternative to MICE for individuals without known disability, as well as clinical populations’ [2]. Furthermore, HIIT might be superior to MICE in persons with heart disease [7]. To improve function, mobility and prevent further disease in stroke survivors there is emerging information from randomized controlled trials (RCTs) that HIIT may be safe and effective.[8] Billinger and colleagues write that “compared to lower intensity, higher intensity training elicits greater improvement in aerobic fitness among healthy adults, persons with heart disease, and persons with stroke”. While we acknowledge that repetitive taks training (RTT) does not mimic high intensity training, we alert the read to the Cochrane Review which found low- to moderate-quality evidence for the effectiveness of repetitive task training (RTT) on upper and lower limb function in patients after stroke [9]. Additionally,Veerbeek et al conclude that RTT intervention should be executed in high-intensity [10].

What are possible benefits of HIIT for stroke survivors?

One study found similar increases in VO2max in four weeks of HIIT compared to 6 months of moderate intensity continuous exercise (MICE) as well as improvements in (persistent hemiparetic) gait, walking economy, walking speed and walking distance in chronic stroke survivors [6]. Another trial compared HIIT with conventional care physiotherapy following moderate stroke demonstrating that HIIT leads to better results in cardiovascular fitness, reflected in improved self-rated functional mobility, i.e. improved independence in performing basic activities of daily living, improved maximum gait speed, balance and quality of life [11].

What is the level of effectiveness and safety in HIIT in stroke survivors? Is it accepted among stroke survivors? 

Some reports suggest that HIIT is feasible and safe in moderate stroke patients [6]. Billinger and colleagues note that “low-intensity exercise can be prescribed for most, if not all, persons with stroke, higher intensities should be prescribed whenever safe and well tolerated because they are generally more effective“. In addition to this, results from a safety analysis show the potential for HIIT in stroke survivors as an adjunct to established (pharmacological) therapy [12].A feasibility study demonstrated its clinical applicability when necessary precautions for high-risk populations were taken into account with the American College of Sports Medicine guidelines [13]. Also, Boyne and colleagues report that HIIT appears to be safe with no serious adverse events being reported. HIIT generally has good acceptance in chronic stroke patients [14].

Could HIIT be a big `HIT` for stroke rehabilitation?

Research in HIIT in stroke survivors is limited to feasibility studies and safety analyses (indicating the effectiveness of HIIT in stroke patients). Some small clinical trials exist, primarily small sample-sized efficacy studies, which limit the generalizability of effects. There is a need for high quality randomized controlled studies to address the questions in this blog.

HIIT for stroke survivors is safe and effective and is well accepted by many patients. HIIT can rapidly show benefits such as improved quality of life in stroke patients. Future research is needed to prove if HIIT has the chance to become the next big `HIT` in neurorehabilitation for stroke survivors.

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Michiel R.M. Twiss @Physiotwiss is a physiotherapist and has a private practice in Buchs SG (Switzerland). He is currently enrolled in a master’s degree in physiotherapy at the University of Applied Sciences in Bern (Switzerland). Email: mrmtwiss@gmail.com

If you would like to contribute to the “Swiss Junior Doctors and Undergraduate Perspective on Sport and Exercice Medicine” Blog Series please email justin.carrard@gmail.comfor further information.

Competing interests

None declared

References

  1. WHO | The top 10 causes of death. (n.d.). Retrieved October 26, 2017, from http://www.who.int/mediacentre/factsheets/fs310/en/
  2. Crozier, J., Roig, M., Eng, J. J., MacKay-Lyons, M., Fung, J., Ploughman, M., … Tang, A. (2018). High-Intensity Interval Training After Stroke: An Opportunity to Promote Functional Recovery, Cardiovascular Health, and Neuroplasticity. Neurorehabilitation and Neural Repair, 32(6–7), 543–556. https://doi.org/10.1177/1545968318766663
  3. Marsden, D. L., Dunn, A., Callister, R., Levi, C. R., & Spratt, N. J. (2013). Characteristics of Exercise Training Interventions to Improve Cardiorespiratory Fitness After Stroke: A Systematic Review With Meta-analysis. Neurorehabilitation and Neural Repair, 27(9), 775–788. https://doi.org/10.1177/1545968313496329
  4. Ivar Gjellesvik, T., Brurok, B., Hoff, J., Tørhaug, T., & Helgerud, J. (2012). Effect of High Aerobic Intensity Interval Treadmill Walking in People With Chronic Stroke: A Pilot Study With One Year Follow-Up. Topics in Stroke Rehabilitation, 19(4), 353–360. https://doi.org/10.1310/tsr1904-353
  5. Pak, S., & Patten, C. (2008). Strengthening to Promote Functional Recovery Poststroke: An Evidence-Based Review. Topics in Stroke Rehabilitation, 15(3), 177–199. https://doi.org/10.1310/tsr1503-177
  6. Biddle, S. J. H., & Batterham, A. M. (2015). High-intensity interval exercise training for public health: a big HIT or shall we HIT it on the head? The International Journal of Behavioral Nutrition and Physical Activity, 12, 95. https://doi.org/10.1186/s12966-015-0254-9
  7. Rognmo, Ø., Hetland, E., Helgerud, J., Hoff, J., & Slørdahl, S. A. (2004). High intensity aerobic interval exercise is superior to moderate intensity exercise for increasing aerobic capacity in patients with coronary artery disease. European Journal of Cardiovascular Prevention and Rehabilitation: Official Journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology, 11(3), 216–222.
  8. Billinger, S. A., Boyne, P., Coughenour, E., Dunning, K., & Mattlage, A. (2015). Does Aerobic Exercise and the FITT Principle Fit into Stroke Recovery? Current Neurology and Neuroscience Reports, 15(2). https://doi.org/10.1007/s11910-014-0519-8
  9. French, B., Thomas, L. H., Coupe, J., McMahon, N. E., Connell, L., Harrison, J., … Watkins, C. L. (2016). Repetitive task training for improving functional ability after stroke.The Cochrane Database of Systematic Reviews, 11, CD006073. https://doi.org/10.1002/14651858.CD006073.pub3
  10. Veerbeek JM, van Wegen E, van Peppen R, van der Wees PJ, Hendriks E, Rietberg M, et al. What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PloS one. 2014;9(2):e87987
  11. Globas, C., Becker, C., Cerny, J., Lam, J. M., Lindemann, U., Forrester, L. W., … Luft, A. R. (2012). Chronic Stroke Survivors Benefit From High-Intensity Aerobic Treadmill Exercise: A Randomized Control Trial. Neurorehabilitation and Neural Repair, 26(1), 85–95. https://doi.org/10.1177/1545968311418675
  12. Carl, D. L., Boyne, P., Rockwell, B., Gerson, M., Khoury, J., Kissela, B., & Dunning, K. (2017). Preliminary safety analysis of high-intensity interval training (HIIT) in persons with chronic stroke. Applied Physiology, Nutrition, and Metabolism,42(3), 311–318. https://doi.org/10.1139/apnm-2016-0369
  13. Askim, T., Dahl, A. E., Aamot, I. L., Hokstad, A., Helbostad, J., & Indredavik, B. (2014). High-Intensity Aerobic Interval Training for Patients 3-9 Months After Stroke. A Feasibility Study: Aerobic Interval Training After Stroke. Physiotherapy Research International, 19(3), 129–139. https://doi.org/10.1002/pri.1573
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