PeRsonalised Exercise for Priming Post-stroke (PREPP): A randomised trial

This is a single study consisting of two phases. Recruited participants will sequentially complete both study phases. All exercise and upper limb training sessions will be conducted in the Exercise Lifestyle Clinic within the Australian Catholic University Strathfield campus. Phase 1: Exercise training is recommended as part of a comprehensive and multidisciplinary stroke rehabilitation program to optimise recovery and reduce the risk of secondary stroke. All participants will undertake a six-week individualised exercise program, prescribed, and delivered by an accredited exercise physiologist, with one-hour exercise sessions completed on three weekdays per week. The exercises will be individualised to each participant based upon their baseline cardiorespiratory fitness (identified using a submaximal cycle ergometer test), their comorbidities and subsequent safety measures that must be taken. Subjective and objective measures taken at numerous timepoints throughout the six-weeks (e.g. Rate of Perceived Exertion, heart rate, assessment results) will be used to identify when the prescription should be amended and whether it needs to be regressed or progressed. The chosen exercises will be selected from aerobic and functional training recommendations for stroke survivors and individualised for each participant. Examples of aerobic exercise include cycling and treadmill walking. Examples of functional exercises include sit-to-stands, step ups and stair climbing. High-Intensity Interval Training (HIIT) style training (e.g. bouts of higher intensity exercise interspersed with lower-intensity exercise) will be progressively introduced during this program to prepare the participant for the HIIT program in Phase 2 of this study. The higher intensity intervals will begin with shorter durations and lower intensities, gradually increasing in duration and intensity as tolerated by the participant. In addition, the HIIT intervals may be spread across the one-hour session in the initial weeks of phase 1 and will be gradually added together in closer temporal proximity as the participant builds their fitness and tolerance. Exercise intensity will be monitored during throughout the exercise session using the Borg RPE scale. When the target RPE is not achieved, the exercise will be modified (made ‘easier’ or ‘harder) during the next session (e.g. increased/decreased resistance, increased/decreased revolutions per minute, more/less repetitions, etc) to ensure the participant reaches the target RPE for that exercise. This will be done to ensure the continued benefit of the program and to build the participant's tolerance for higher intensity exercise (e.g. 14-17/20 RPE). Phase 2: Following the completion of the six-week individualised exercise program, participants will be randomised into one of two groups to undertake a two-week program of combined HIIT + modified-Constraint-Induced Movement therapy (mCIMT). The HIIT protocol will require participants to complete 4x4 minute intervals delivered on a bicycle ergometer (85% heart rate reserve [HRR]) interspersed with a three-minute active recovery (70% HRR), totalling 45 minutes of cycling. The mCIMT involves one-hour time on task of supervised task-oriented training augmented by progressively increasing home practice. The tasks provided will be individualised to the participant, based upon their motor function and requirements (e.g. shifting pegs, placing screws on a pipe, using cutlery, etc). Participants will be required to wear a mitt on the non-paretic limb for up to 90% of waking hours (to be removed for ambulation, toileting and other activities deemed unsafe) as part of the mCIMT transfer package. All HIIT and mCIMT sessions will be supervised by a trained accredited exercise physiologist. The transfer package is a set of behavioural interventions that aim to promote the transfer of clinic gains to daily function, including a behavioural contract and Motor Activity Log (MAL) to promote safety and monitor adherence to home practice, paretic limb use and mitt compliance during mCIMT, and to provide an opportunity for goal-setting and problem solving. Group 1 will undertake HIIT before the mCIMT session, and Group 2 will undertake HIIT after the mCIMT session. Both HIIT and mCIMT sessions will be prescribed and delivered by an accredited exercise physiologist trained in mCIMT, with the HIIT sessions completed on three weekdays per week and the mCIMT sessions completed on 10 consecutive weekdays. An ActiGraph will be worn by the participant during Phase 1 and Phase 2 to monitor physical activity completed outside of the supervised sessions. The study team will download and recharge the ActiGraphs when the participant attends the clinic for their supervised sessions and will examine the data collected. The duration of moderate-to-high intensity exercise will be recorded and added to their weekly total. Adherence of the sessions (Phase 1 and Phase 2) will be monitored using attendance checklists.