Stroke is a leading cause of serious long-term physical disability due to insufficient neurorepair mechanisms. In general, physical activity is an important modifiable risk factor, particularly for stroke and cardiovascular diseases. Physical exercise has shown to be neuroprotective in both animal experiments and clinical settings. Exercise can be considered a mild stressor and follows the prototypical preconditioning stimulus. It has beneficial effects on brain health and cognitive function. Preconditioning exercise, which is prophylactic exercise prior to ischemia, can protect the brain from subsequent serious injury through promotion of angiogenesis, mediation of inflammatory responses, inhibition of glutamate over-activation, protection of the blood-brain barrier, and inhibition of apoptosis. Preconditioning exercise appears to induce brain ischemic tolerance and it has been shown to exert beneficial effects. It is clinically safe and feasible and represents an exciting new paradigm in endogenous neuroprotection for patients with acute stroke. In this review, we describe the neuroprotective potential of preconditioning exercise and clinical applications in patients with acute ischemic stroke.

Objective: Gait ability may be related to the level of intensity-based physical activity in people who have experienced a stroke; however, this relationship has not been explored in previous studies. This study aimed to investigate the characteristics of intensity-based physical activity according to gait ability and to explore the factors related to different intensity physical activity. Method: Eighty hospitalized participants with subacute stroke were assigned to three groups based on their gait ability: group 1 (n = 28) could walk independently with a maximal gait speed (MGS) of more than 0.9 m/s; group 2 (n = 11) could walk independently with a MGS of less than 0.9 m/s; group 3 (n = 41) could not walk independently. Light-intensity physical activity (LIPA) and moderate-to-vigorous physical activity (MVPA) were measured for 12 hours using an accelerometer (OMRON, HJA350-IT) for 7 consecutive days and were calculated throughout three time periods (daytime, non-therapy time, or therapy time). Results: In each time period, a two-way ANOVA showed an interaction between the groups and intensity-based physical activity (p < 0.05). Bonferroni post hoc test showed a significantly higher LIPA in groups 1 and 2 compared with group 3 in daytime or non-therapy time. In contrast, group 1 showed a significantly higher MVPA compared with group 2 and 3 for each time period. Conclusion: During daytime and non-therapy time, the results suggested that gait independence is related to LIPA rather than gait speed, and gait speed and gait independence is related to MVPA.

Purpose: This study aimed to calculate cut-off values of activities of daily living independence level for stroke patient home discharge based on the number of family caregivers. Method: The subjects comprised 1442 stroke patients (26 hospitals) who were registered of the Japanese Rehabilitation Database. Receiver operating characteristic curves were used to elucidate the BI and FIM^® instrument scores necessary for home discharge. Analysis was performed for each subject according to the number of family caregivers, i.e., no caregiver, one person, two persons or more, and overall. Result: The BI cut-off points that discriminated between home discharge and other were 65/60 points overall, 75/70 points in patients with no caregiver, 65/60 points in patients with one caregiver, and 60/55 points in patients with two or more caregivers. The FIM^® instrument cut-off points were 90/89 points overall, 101/100 points in patients with no caregiver, 87/86 points in patients with one caregiver, and 87/86 points in patients with two or more caregivers. Conclusion: Our results indicated that home discharge for patients with many caregivers was possible even with low ADL independence levels, and that there was a large difference in cut-off values depending on the presence or absence of one caregiver.

Objective: To investigate the correlation between changes of contralesional cortical excitability evaluated by transcranial magnetic stimulation (TMS) and functional recovery in patients with hemiparetic stroke. Methods: Eight inpatients (mean age: 75.9±13.8 years) with mild to moderate hemiparesis were enrolled. TMS was delivered to the optimal scalp position over the contralesional (ipsilateral to the paresis) primary motor cortex (M1) to activate the unaffected flexor carpi radialis muscle (FCR) while the patient picked up a wooden block with the affected hand. The amplitude of the motor-evoked potential (MEP) was measured and then was divided by the resting MEP amplitude (MEP ratio). For evaluation of motor function, we tested grip strength (GS), performed the upper extremity motor section of the Fugl-Meyer Assessment (FMA-UE), and performed the Purdue Pegboard Test (PPT) when the patients were admitted to our hospital (T1) and 2 months after admission (T2). Results: The MEP ratio was significantly decreased at the second examination. The partial correlations between the MEP ratio and FMA-UE at T1, and PPT of an affected hand at T2 were observed while controlling for the period after stroke onset as the confounding variable. Conclusion: The reduction of contralesional cortical hyperactivity is related to the functional recovery in part, but not related with the period after stroke onset. This suggests that enhanced reduction of contralesional M1 hyperactivity contributes to functional recovery after stroke.

Objective: To assess factors associated with changes in blood pressure during early mobilization protocol for patients with acute ischemic stroke who were treated with mechanical thrombectomy. Design: Retrospective observational study. Method: We analyzed patients with acute ischemic stroke who were treated with mechanical thrombectomy (MT group, n=60) and patients who received conservative medical management (control group, n=60) matched by age and National Institute Health of Stroke Score at admission from April 2009 to July 2014. The proportion of patients with prominent blood pressure change during an early mobilization protocol was compared between the MT group and control group. Factors associated with prominent blood pressure change were also analyzed using multivariable logistic regression analysis. Result: The deviation in blood pressure response was much more significant in the MT than control group (13.3 vs. 1.7%, p<0.016). Logistic regression analysis showed the interval from admission to being able to sit in a wheelchair associated with prominent changes in blood pressure (odds ratio, 1.604; 95% confidence interval, 1.196-2.150; p<0.002). Conclusion: Our results showed that prominent changes in blood pressure during an early mobilization protocol can occur easily in patients with acute ischemic stroke after mechanical thrombectomy.

Purpose: This study aimed to clarify which cognitive and physical factors are associated with the need for toileting assistance in stroke patients and to calculate cut-off values for discriminating between independent supervision and dependent toileting ability. Method: This cross-sectional study included 163 first-stroke patients in nine convalescent rehabilitation wards. Based on their FIM^® instrument score for toileting, the patients were divided into an independent-supervision group and a dependent group. Multiple logistic regression analysis and receiver operating characteristic analysis were performed to identify factors related to toileting performance. The Minimental State Examination (MMSE); the Stroke Impairment Assessment Set (SIAS) score for the affected lower limb, speech, and visuospatial functions; and the Functional Assessment for Control of Trunk (FACT) were analyzed as independent variables. Result: The multiple logistic regression analysis showed that the FIM^® instrument score for toileting was associated with the SIAS score for the affected lower limb function, MMSE, and FACT. On receiver operating characteristic analysis, the SIAS score for the affected lower limb function cut-off value was 8/7 points, the MMSE cut-off value was 25/24 points, and the FACT cut-off value was 14/13 points. Conclusion: Affected lower limb function, cognitive function, and trunk function were related with the need for toileting assistance. These cut-off values may be useful for judging whether toileting assistance is needed in stroke patients.