What is the appropriate exercise regimen for a patient with an acute cerebral vascular disease (CVD) infarct in the right middle cerebral artery territory, likely of cardioembolic origin, presenting with significant left-sided motor weakness?

Exercise Recommendations for Acute Cardioembolic MCA Stroke

Yes, structured exercise rehabilitation is not only applicable but strongly recommended for patients with acute cardioembolic right MCA infarction presenting with left-sided motor weakness, beginning with early mobilization during hospitalization and progressing to comprehensive aerobic, resistance, and neuromuscular training programs. 1

Acute Inpatient Phase: Early Mobilization

Walking should begin as soon as the patient is medically stable (stable ECG, vital signs, and symptoms), as the primary goal during hospitalization is avoiding the deleterious effects of bed rest. 1

• Monitor for signs of over-exercising including inability to finish sessions, inability to converse during activity, faintness or nausea after exercise, chronic fatigue, sleeplessness, and joint aches or pains. 1
• Start slowly and progress gradually, allowing time for physiological adaptation. 1
• Given the cardioembolic etiology, ensure cardiac monitoring is in place as these patients have high risk for recurrent embolic events (in-hospital mortality 27.3%, with 77% mortality if early recurrence occurs within 7 days). 2

Post-Acute Exercise Prescription Framework

Aerobic Training Parameters

Stroke survivors should perform aerobic exercise at least 3 days per week for 20-60 minutes per session, with the specific duration depending on functional capacity. 1

• Target intensity: 40-70% of heart rate reserve (calculated as: [(maximal HR - resting HR) × 40-70%] + resting HR), which corresponds to a rating of perceived exertion of 11-12 on the 6-20 scale or resting heart rate plus 20 bpm. 1
• For patients unable to tolerate a single 20-60 minute session, multiple short bouts of 10-15 minutes repeated throughout the day (interval training approach) are equally effective and often better tolerated. 1
• If symptomatic or silent myocardial ischemia is present (relevant given cardioembolic origin often indicates underlying cardiac disease), set target heart rate at least 10 bpm below the ischemic ECG or anginal threshold. 1

Treadmill Walking: The Preferred Modality

Treadmill walking offers three distinct advantages for stroke survivors with motor weakness: it trains a functional daily activity (enhancing generalizability), allows use of handrail support and unweighting harnesses for patients unable to walk independently, and permits intensity augmentation via grade increases when gait/balance limitations preclude faster speeds. 1

• Walking at 2 mph on level ground = approximately 2 METs; at 3 mph = approximately 3 METs. 1
• At 2 mph, each 3.5% grade increase adds approximately 1 MET. 1
• At 3 mph, each 2.5% grade increase adds approximately 1 MET. 1

Resistance Training Protocol

Resistance training should be performed 2-3 days per week to maximize independence in activities of daily living and reduce cardiac demands during daily tasks like carrying groceries. 1

• Prescribe 10-15 repetitions per set (higher repetitions with reduced loads), similar to post-myocardial infarction protocols, given the cardioembolic etiology suggests underlying cardiac disease. 1
• Include minimum of 1 set of 8-10 different exercises involving major muscle groups of torso, upper extremities, and lower extremities. 1
• Perform on non-consecutive days to allow recovery. 1

Adjunctive Training Components

Flexibility training and neuromuscular exercises (including yoga, tai chi, modified recreational activities) improve balance, quality of life, mental health, and reduce fear of falling. 1

• These modalities are particularly important for right MCA stroke patients who may have left-sided neglect and balance impairments. 1

Exercise Testing Considerations

Peak or symptom-limited exercise testing should be considered before beginning vigorous exercise (≥60% heart rate reserve or ≥6.0 METs) in stroke survivors at risk for exertion-related cardiovascular events. 1

• However, early outpatient medically supervised exercise rehabilitation without preliminary exercise testing has demonstrated safety and effectiveness when using rating of perceived exertion (11-12 on 6-20 scale) or resting heart rate plus 20 bpm with continuous ECG monitoring. 1
• This approach corresponds to approximately 42% VO2 reserve, which approximates the minimum threshold intensity for improving cardiorespiratory fitness. 1

Critical Safety Considerations for Cardioembolic Stroke

Given the cardioembolic etiology, several precautions are essential:

• Anticoagulation status must be optimized immediately if no contraindications exist (falls, poor compliance, uncontrolled epilepsy, gastrointestinal bleeding), as recurrent cardioembolic stroke risk is highest in the acute phase. 3, 2
• Patients with alcohol abuse, hypertension, valvular heart disease, nausea/vomiting, or previous cerebral infarction have increased risk of early recurrent systemic embolization. 2
• Cerebrovascular hemodynamics may be attenuated during exercise post-stroke, with middle cerebral artery velocity amplitude potentially reduced by 50% or more on the affected side. 4, 5
• Exercise should be stopped immediately if inappropriate signs or symptoms develop (chest pain, severe dyspnea, dizziness, new neurological symptoms). 1

Optimal Frequency and Duration

Physiotherapy should be provided at least 3 times per week, with total therapy time ideally reaching 3 hours per day across 5 days per week when combining physiotherapy, occupational therapy, and speech therapy. 6

• Where 3 hours daily is not feasible, ensure therapy is still offered minimum 5 days per week. 6
• Aerobic exercise should continue for at least 8 weeks minimum to achieve meaningful cardiorespiratory improvements. 6

Common Pitfalls to Avoid

• Do not delay exercise initiation beyond medical stabilization, as early mobilization prevents deconditioning and the vicious cycle of fatigue leading to further inactivity. 1, 6
• Do not prescribe exercise intensity based solely on age-predicted maximum heart rate in cardioembolic stroke patients; use heart rate reserve method or perceived exertion with cardiac monitoring. 1
• Do not ignore the cardiac source of embolism; structural heart defects, atrial fibrillation, recent myocardial infarction, mechanical valves, or dilated cardiomyopathy require specific cardiac management alongside stroke rehabilitation. 3, 2
• Do not provide less than 3 sessions per week, as this results in suboptimal recovery outcomes. 6