The Effect of Combination of Calcium Supplement and Physical Exercise on Increasing Muscle Strength in Chronic Ischemic Stroke Patients

Introduction: Stroke causes muscle weakness which results in limitations in daily activities such as self-care, eating, walking, etc. This study aims to evaluate the effect of calcium supplement and physical exercise on increasing muscle strength in chronic ischemic stroke patients. Methods: This research was conducted at Dadi Makassar Hospital and Haji Hospital from March to May 2023. The sample obtained was 37 subjects based on purposive sampling with an unpaired numerical comparative formula for two sample groups consisting of 18 people in the treatment group and 19 people in the control group. The research was carried out for 6 weeks using a Manual Muscle Testing (MMT) measuring instrument for muscle strength. Results: There is a significant increase in lower extremity muscle strength between the pre-test and post-test in the treatment group and control group (p=0.001; p=0.014, p<0.05), There is an increase in the upper extremity muscle strength between the pre-test and post-test in the treatment group and control group (p=0.001; p=0.025). There is no significant difference in the increase in muscle strength in the upper and lower limbs between the two groups (p=0.051). Conclusion: Physical exercise with calcium supplements are not more significant in increasing muscle strength than physical exercise alone in chronic ischemic stroke patients.


INTRODUCTION
Stroke is an acute neurological disorder of the blood vessels in the brain due to the blood supply to an area of the brain stopping, causing tissue cells to lack oxygen [1].Chronic ischemic stroke sufferers will experience problems in the form of muscle weakness which results in impaired ADL.This decrease in muscle strength is due, in part, to increased levels of calcium (Ca2+) in the blood [2] which plays a role in the signal transduction pathway to carry messages in the release of neurotransmitters from neurons [3] and contraction of muscle cells.This metabolic disorder will cause subsequent injury to neurons which will trigger rapid translocation of Ca2+ ions from the extracellular space to the intracellular tissue [4].After a chronic ischemic stroke, pathological disturbances occur in the tissue, namely a leak in the Ca2+ channel signaling pathway which causes an increase in Ca2+ levels at the cytosolic level which results in disruption of protease activation which is highly dependent on Ca2+ ions [5].
The calpain in the protease will degrade myofilaments so that it can cause muscle weakness and Acute Respiratory Failure Disruption of Ca2+ signaling will affect the regulation of muscle contractile strength in muscle fibers as well as disruption of Ca2+ ion homeostasis which results in muscle weakness [6].gravity with maximum resistance, with a level of reliability and validity 95%, r=0,768 with pvalue = 0,001 [12].

Data collection
Data

Analysis
The From these data, it can be concluded that the effect of providing calcium supplements and physical exercise did not provide a significant difference in muscle strength in both superior and inferior limb in chronic ischemic stroke patients.[14], there is an increase in insulin secretion which increases systolic calcium by regulating the activation of calcium channels which play a role in the lipolysis process.The transport of glucose in muscles requires the help of GLUT4 to the membranes in muscle fibers to be converted into ATP [15].The increase in calcium concentration that enters intracellularly during muscle contraction will activate AMP kinase (AMPK), which is the fuel that will be used in physical exercise [16].
Age can affect changes in muscle strength capabilities caused by changes in the composition of fat-free mass (FFM) which is used as a source of energy reserves needed for muscle contraction.According to the previous research, after the age of 45 years, there is a decrease in FFM from 62 kg to 55 kg in men and from 48 kg to 39 kg in women so women allow less ATP to be produced for use in muscle contraction.Likewise, women and men also contribute to this change, where women have more fat deposits compared to men who have more muscle tissue [17].
At the CNS level, when there is a lack of calcium levels in the cells (hypocalcemia) it causes motor damage due to a decrease in dopamine concentrations in the nigrostriatal pathway which plays a role in nerve transmission [18], so when calcium levels in the cells are met, the dopamine substantia nigra will release dopamine from the presynaptic axonal to the striatum and from the dendritic soma area to the midbrain [6] which will mediate the physiological function of dopamine neurons in nerve synapse transmission which will reduce the conductivity of peripheral motor neurons thereby reducing the tingling feeling, especially in the arms and legs [19].
In the muscle, there is an increase in calcium concentration of around 100 to 200 mmol/l which will penetrate the intracellular membrane against the cell gradient of the endoplasmic and sarcoplasmic reticulum.
However, only a portion of the calcium concentration can penetrate the permeability of Ca2+ channels to enter intracellularly, where most cells that can be excited at rest permeability to calcium are only in low amounts [20].In contrast, when muscle contraction occurs, the intracellular calcium concentration will also increase, which will increase the ability of the actin folds and also When physical exercise is carried out there is an increase in NEFA and calcium intake will increase the level of fat oxidation [20].Apart from that, in this study it was found that there cells, but this still needs to be proven [3].
Other research states that reducing calcium absorption by the sarcoplasmic reticulum, reducing extracellular calcium concentrations, and inhibiting the calcium entry pathway will increase fatigue [18].
Calcium intake will help utilize fat as the main energy source during exercise which will increase the availability of NEFA so that it can help increase fat oxidation during certain physical exercises.This can help reserve glycogen for certain exercises which will improve muscle contraction performance and delay fatigue [21].
The amount of calcium taken up during muscle contraction is related to the extracellular calcium concentration and increased calcium uptake cannot be maintained during sustained stimulation during physical exercise but may decrease over time.Due to the inactivation of the calcium concentration, the intracellular calcium concentration increases to the point where it will damage cells and reduce the muscle contraction response, so when there is an excess increase in calcium concentration, it must be balanced and reduced by physical exercise which will be used in the ECC mechanism during muscle contraction [23].
The more calcium that can be used in this mechanism, the stronger and longer the intensity of the ECC action during contraction, so that the muscle work adaptation mechanism will increase muscle strength [22].
Giving calcium supplements increases tissue and muscle mass, especially in men, when followed by physical exercise.This allows performance related to daily activities such as eating, bathing, toileting, ambulances, walking, and so on.The decrease in activity for women is also influenced by hormonal factors such as the hormone estrogen which will increase fat stores in subcutaneous tissue, allowing muscle performance to decrease further.In addition, the risk of experiencing osteoporosis is greater which will affect bone density when doing activities.According to research, after the age of 45 years, there is a decrease in FFM from 62 kg to 55 kg in men and from 48 kg to 39 kg in women so women allow less ATP to be produced for use in muscle contraction.In this study, it was stated that changes in FFM in the upper and lower legs were associated with a sedentary lifestyle so the legs had the ability to protect against insulin resistance and dyslipidemia apart from total fat mass [3].Other research also states that FFM in the legs is a determinant of cardiometabolic risk after menopause which results in bone loss, so that bones become brittle due to reduced estrogen hormones in women and testosterone in men which affects calcium transport and reabsorption [24].
Apart from that, stroke recovery in old age is more focused on improving cardiorespiration, namely in the form of increasing fitness reserves, increasing Vo2Max and increasing walking ability [25].

LIMITATIONS
This study has a small sample size because some patients were dropped out.Likewise, additional doses of calcium supplements also need to be taken into account, namely 1000 -2000 mg with the consideration of further improving the ECC mechanism in muscles.
Apart from that, psychological disorders in the form of depression can also cause problems to influence the patient's motivation to exercise, thereby impacting recovery.

NURSING IMPLICATION
This research can be used as complementary therapy in nursing in treating chronic ischemic stroke patients by combining drugs such as supplements and physical exercise so that it will further increase the ability of muscle strength that experiences post-stroke weakness.
collection in the study began by selecting the patients according to the inclusion criteria.If the sample meets the criteria, the researcher asked for informed consent to the patients by explaining the purpose of this research as well as indications and contraindications for giving calcium supplements and physical exercise.After obtaining approval from the patients, the researcher checked the MMT (pre-test) on the upper and lower extremities in the first week, then the patients received a calcium supplement of 500 mg/day every morning before training and physical exercise "bobath exercises" 3 times a week for 6 weeks, while the control group received physical exercise only 3 times a week for 6 weeks.The Muscle strength will be measured again using Manual Muscle Testing (MMT) [13] at week six (posttest).Proprioceptive Neuromuscular Facilitation (PNF) and stretching were done by a physiotherapist at the hospital.The researchers only measure and observe the patient's development during therapy.Measurements of the muscle strength of the patients were taken by the researchers to avoid measurement errors.

Fig. 1 .
Fig. 1.Comparison of Superior Extremity Muscle Strength Between Two Groups

Fig. 2 .
Fig. 2. Comparison of Inferior Extremity Muscle Strength Between Two Groups the myosin cross bridges in the ECC mechanism.It is the molecular capabilities of proteins involved in calcium signaling that can determine the specific interactions between stimulation and changes in organelle state[21].Because most of the cellular calcium is in a bound state, an increase in calcium in the cells will trigger secretion in the sarcoplasmic and endoplasmic reticulum as a calcium storage place to release the bound calcium.The stimulation of the secretion process in the glands can occur by changing the state of bound calcium.This is related to the action of pituitary hormones on the adrenal cortex and thyroid gland to secrete calcium which will be used in the muscle contraction mechanism.The stimulation of the secretion process in the glands can occur by changing the state of bound calcium[6].Providing calcium supplements during physical exercise will help restore energy deficits so that it can increase training sessions that initially could only be done one training session but can now be done two or three training sessions.This is due to a decrease in the rate of fat oxidation which will increase Non-esterified Fatty Acid (NEFA).
was a decrease in fatigue during and after training, especially training with medium and high intensity, which allows the frequency and intensity of training to be increased to maximize muscle work.This fatigue occurs due to changes in ion concentration in the form of an excessive increase in extracellular calcium concentration which will affect the slowing of relaxation in muscle fibers which occurs due to repeated contractile activation, so reducing calcium concentration during physical exercise will reduce fatigue.The previous study shows that reducing the calcium concentration of myoplasm will reduce fatigue.However, there is another opinion that says that increased calcium concentrations can be normalized or reduced by reducing calcium sensitivity in muscle Providing calcium supplements and physical exercise have a more significant effect on increasing muscle strength, but statistically when comparing the two interventions, it shows that there is no specific difference between the two treatments in increasing muscle strength in chronic ischemic stroke patients.It is hoped that there will be further research regarding the effect of calcium supplements and physical exercise on increasing muscle strength in chronic ischemic stroke patients by paying attention to aspects of checking calcium and hormonal levels, psychological influences, training doses, and appropriate techniques.

Table 1
Respondent Characteristics

Table 2
Comparison of Superior and Inferior Extremity Muscle Strength