Lower-limb motor coordination is significantly impaired in ambulatory people with chronic stroke: A cross-sectional study

OBJECTIVES

To establish the deficits of motor coordination of the lower limbs after stroke, in comparison with healthy controls, and to investigate whether the magnitude of the deficits would be influenced by the levels of motor recovery.

DESIGN

Cross-sectional study.

SUBJECTS

Chronic stroke patients and healthy subjects.

METHODS

Lower-limb motor coordination of both stroke and healthy volunteers was measured using the Lower Extremity Motor Coordination Test (LEMOCOT). The motor coordination deficits of the participants with stroke were analysed all together and separated, according to their levels of motor recovery, measured using the Fugl-Meyer lower-limb motor section scores.

RESULTS

Ninety-seven individuals with chronic stroke, 55 men, mean age 58 years, were evaluated. Motor coordination was significantly impaired on both paretic (mean: -22 touches; 95% confidence interval (95% CI) -24 to -19; deficit: 61%) and non-paretic (mean -6 touches; 95% CI -8 to -4; deficit: 17%) lower limbs. Significant differences in the LEMOCOT scores were found between the levels of motor recovery (p < 0.01), except between the participants with marked and moderate impairments.

CONCLUSION

Motor coordination of the lower limbs is significantly impaired after stroke, but the deficits of the non-paretic lower limb (17%) appear not to be clinically relevant. These findings suggest that interventions prescribed to improve motor coordination after stroke should focus on the paretic lower limb and/or include bilateral activities.

Efficacy of interventions to improve physical activity levels in individuals with stroke: a systematic review protocol

INTRODUCTION

Stroke is a leading health problem worldwide and an important cause of disability. Stroke survivors show low levels of physical activity, and increases in physical activity levels may improve function and health status. Therefore, the aims are to identify which interventions that have been employed to increase physical activity levels with stroke survivors, to verify their efficacy and to identify the gaps in the literature.

METHODS AND ANALYSIS

A systematic review of randomised controlled trials that investigated the efficacy of interventions aiming at increasing physical activity levels of stroke survivors will be conducted. Electronic searches will be performed in the MEDLINE, Physiotherapy Evidence Database (PEDro), Excerpta Medica (EMBASE), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) and Scientific Electronic Library Online (SCIELO) databases. Hand searches of the reference lists of the included studies or relevant reviews will also be employed. Two independent reviewers will screen all the retrieved titles, abstracts and full texts. A third reviewer will be referred to solve any disagreements. The quality of the included studies will be assessed by the PEDro Rating Scale. This systematic review will also include a qualitative synthesis. Meta-analyses will be performed, if the studies are sufficiently homogeneous. This review will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The quality of the evidence regarding physical activity will be assessed, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

DISCUSSION

This systematic review will provide information on which interventions are effective for increasing physical activity levels of stroke survivors. This evidence may be important for clinical decision-making and will allow the identification of gaps in the literature that may be useful for the definition of future research goals and the planning of new trials.

TRIAL REGISTRATION NUMBER

CRD42016037750.

Walking training associated with virtual reality-based training increases walking speed of individuals with chronic stroke: systematic review with meta-analysis

OBJECTIVE:

To systematically review the available evidence on the efficacy of walking training associated with virtual reality-based training in patients with stroke. The specific questions were: Is walking training associated with virtual reality-based training effective in increasing walking speed after stroke? Is this type of intervention more effective in increasing walking speed, than non-virtual reality-based walking interventions?

METHOD:

A systematic review with meta-analysis of randomized clinical trials was conducted. Participants were adults with chronic stroke and the experimental intervention was walking training associated with virtual reality-based training to increase walking speed. The outcome data regarding walking speed were extracted from the eligible trials and were combined using a meta-analysis approach.

RESULTS:

Seven trials representing eight comparisons were included in this systematic review. Overall, the virtual reality-based training increased walking speed by 0.17 m/s (IC 95% 0.08 to 0.26), compared with placebo/nothing or non-walking interventions. In addition, the virtual reality-based training increased walking speed by 0.15 m/s (IC 95% 0.05 to 0.24), compared with non-virtual reality walking interventions.

CONCLUSIONS:

This review provided evidence that walking training associated with virtual reality-based training was effective in increasing walking speed after stroke, and resulted in better results than non-virtual reality interventions.

Previous lower limb dominance does not affect measures of impairment and activity after stroke

BACKGROUND

Similar to the findings with the upper limbs, previous dominance of the lower limbs could also interfere with measures of impairment and activity of individuals with stroke. If this occurs, rehabilitation interventions should be planned, considering previous lower limb dominance.

AIM

To investigate the impact of having the dominant versus the non-dominant lower limb affected by the stroke on measures of impairment and activity.

DESIGN

Cross-sectional study.

SETTING

University laboratory.

POPULATION

Ninety subjects with chronic stroke, divided into dominant (n=44) and non-dominant (N.=46) groups.

METHODS

The sub-groups were classified according to the severity of motor impairments into mild and severe. Impairment measures included sensation, tonus, isometric strength and motor coordination, whereas activity measures included walking speed, and stair ascent/descent cadences.

RESULTS

The MANOVAs did not reveal any significant interactions between dominance and severity of motor impairments for both the impairment and activity models. Significant main effects of severity of motor impairments were found for both the impairment and activity models, but not for dominance. All dependent variables were significantly affected by the severity of motor impairments, but not by dominance.

CONCLUSIONS

The findings suggested that individuals, who had their dominant lower limb affected by the stroke, demonstrated similar impairments, than those who had the non-dominant lower limb affected. Furthermore, significant effects of severity of motor impairments, but not of dominance, were found on all measures of impairment and activity.

CLINICAL REHABILITATION IMPACT

The findings emphasize the importance of not training the lower limbs based upon previous dominance, but giving priority to bilateral training. When both limbs are simultaneously used in tasks, the movement of the non-dominant limb improves the quality of the movement, accuracy, and speed, because bilateral training helps the unaffected side to train the affected side.

Modified sphygmomanometer test for the assessment of strength of the trunk, upper and lower limbs muscles in subjects with subacute stroke: reliability and validity

BACKGROUND

Limitations in activities have been related to weakness of the upper limbs (UL), lower limbs (LL) and trunk muscles after stroke. Therefore, the measurement of strength after stroke becomes essential. The Modified Sphygmomanometer Test (MST) is an alternative method for the measurement of strength, since it is cheap and provides objective values. However, no studies have investigated the measurement properties of the MST in sub-acute stroke.

AIM

To investigate the test-retest and inter-rater reliabilities and criterion-related validity of the MST for the measurement of strength of the UL, LL, and trunk muscles in subjects with sub-acute stroke, and verify whether the number of trials would affect the results.

DESIGN

Diagnostic accuracy.

SETTING

Local community, out-patient clinics, and university laboratory.

POPULATION

Sixty- five subjects with sub-acute stroke (62±14 years) participated of the present study.

METHODS

The strength of 36 muscular groups was measured with the MST and dynamometers (criterion standard). To investigate whether the number of trials would affect the results, analysis of variance was applied. For the test-retest and inter-rater reliabilities and criterion-related validity of the MST, intra-class correlation coefficients (ICC), Pearson correlation coefficients, and coefficients of determination were calculated.

RESULTS

Similar results were found for all muscular groups and number of trials (0.01≤F≤0.14; 0.87≤p≤0.99) with significant and adequate values of test-retest (0.57≤ICC≥0.98) (exception: first trial of the non-paretic ankle dorsiflexors) and inter-rater (0.50≤ICC≥0.99) (exception: non-paretic ankle plantar flexors) reliabilities and validity (0.70≤r≥0.95; p≤0.001). The values obtained with the MST were good predictors of those obtained with the dynamometers (0.54≤r2≤0.90).

CONCLUSIONS

In general, the MST showed adequate reliabilities and criterion-related validity for measuring strength of subjects with sub-acute stroke, and only one trial, after familiarization, provided adequate values.

CLINICAL REHABILITATION IMPACT

The MST can be used by health professionals within several clinical contexts to objectively measure strength of the UL, LL, and trunk muscles in subjects with sub-acute stroke. Besides providing objective, reliable, and valid strength measures, the MST is also feasible. The aneroid sphygmomanometer used for the MST assessment is portable, easily found worldwide, and commonly acquired by health professionals. Furthermore, its adaptation is simple, reversible, and cheap.

Dynamometry for the measurement of grip, pinch, and trunk muscles strength in subjects with subacute stroke: reliability and different number of trials

Background

Muscle strength is usually measured in individuals with stroke with Portable dynamometers (gold standard). However, no studies have investigated the reliability, the standard error of measurement (SEM) and the minimal detectable difference (MDD_95%) of the dynamometry for the measurement of hand grip, pinch grip and trunk strength in subjects with subacute stroke.

Objective

1) To investigate the intra and inter-rater reliability, the SEM and the MDD_95% of the portable dynamometers for the measurement of grip, pinch and trunk strength in subjects with subacute stroke, and 2) to verify whether the use of different number of trials (first trial and the average of the first two and three trials) affected the results.

Method

32 subjects with subacute stroke (time since stroke onset: 3.6 months, SD=0.66 months) were evaluated. Hand grip, 3 pinch grips (i.e. pulp-to-pulp/palmar/lateral) and 4 trunk muscles (i.e. flexors, extensors, lateral flexors and rotators) strength were bilaterally assessed (except trunk flexors/extensors) with portable dynamometry by two independent examiners over two sessions (1-2 weeks apart). One-way ANOVAs and intraclass correlation coefficients (ICC_2,k) were used for analysis (α=0.05). SEM and MDD_95% were also calculated.

Results

For all muscular groups and sources of outcome values, including one trial, after familiarization, similar results were found (0.01≤F≤0.08; 0.92≤p≤0.99) with significant and adequate values of intra-rater (0.64≤ICC≤0.99; 0.23≤95%CI≤0.99) and inter-rater (0.66≤ICC≤0.99; 0.25≤95%CI≤0.99) reliability. SEM and MDD_95% were considered low (0.39≤EPM≤2.21 Kg; 0.96≤MMD_95%≤6.12 Kg) for all outcome scores.

Conclusion

Only one trial, following familiarization, demonstrated adequate intra-rater and inter-rater reliability of the portable dynamometers for the measurement of hand grip, pinch grip and trunk strength in subjects with subacute stroke.

Respiratory muscle training increases respiratory muscle strength and reduces respiratory complications after stroke: a systematic review

QUESTION

After stroke, does respiratory muscle training increase respiratory muscle strength and/or endurance? Are any benefits carried over to activity and/or participation? Does it reduce respiratory complications?

DESIGN

Systematic review of randomised or quasi-randomised trials.

PARTICIPANTS

Adults with respiratory muscle weakness following stroke.

INTERVENTION

Respiratory muscle training aimed at increasing inspiratory and/or expiratory muscle strength.

OUTCOME MEASURES

Five outcomes were of interest: respiratory muscle strength, respiratory muscle endurance, activity, participation and respiratory complications.

RESULTS

Five trials involving 263 participants were included. The mean PEDro score was 6.4 (range 3 to 8), showing moderate methodological quality. Random-effects meta-analyses showed that respiratory muscle training increased maximal inspiratory pressure by 7 cmH2O (95% CI 1 to 14) and maximal expiratory pressure by 13 cmH2O (95% CI 1 to 25); it also decreased the risk of respiratory complications (RR 0.38, 95% CI 0.15 to 0.96) compared with no/sham respiratory intervention. Whether these effects carry over to activity and participation remains uncertain.

CONCLUSION

This systematic review provided evidence that respiratory muscle training is effective after stroke. Meta-analyses based on five trials indicated that 30minutes of respiratory muscle training, five times per week, for 5 weeks can be expected to increase respiratory muscle strength in very weak individuals after stroke. In addition, respiratory muscle training is expected to reduce the risk of respiratory complications after stroke. Further studies are warranted to investigate whether the benefits are carried over to activity and participation.

REGISTRATION

PROSPERO (CRD42015020683). [Menezes KKP, Nascimento LR, Ada L, Polese JC, Avelino PR, Teixeira-Salmela LF (2016) Respiratory muscle training increases respiratory muscle strength and reduces respiratory complications after stroke: a systematic review.Journal of Physiotherapy62: 138-144].

Potential predictors of lower extremity impairments in motor coordination of stroke survivors

BACKGROUND

It is well recognized that the negative motor impairments following upper motor neuron damage, e.g., loss of strength and dexterity (motor coordination), mostly contribute to disability. Many factors may predict impairments in motor coordination (MC) and the identifications of these factors could help rehabilitation professionals to select variables to be considered in the evaluation and interventions aimed at improving MC of the lower limbs after stroke.

AIM

To investigate the potential predictors of motor coordination (MC) of the paretic lower limb with stroke subjects, as assessed by the Lower Limb Motor Coordination Test (LEMOCOT).

DESIGN

Cross-sectional, observational study.

SETTING

University laboratory.

POPULATION

One hundred and six stroke subjects.

METHODS

The selected potential predictors of the LEMOCOT scores were age, gender, motor recovery and sensation of the lower limb, tonus of the knee extensor and plantar flexor muscles, and strength of the hip flexor and knee flexor/extensor muscles. Step-wise multiple regression was employed for analysis.

RESULTS

Only motor recovery, tonus of the plantar flexor muscles, and age reached significance (P<0.05) and, consequently, were kept in the model. Motor recovery alone was able to explain 46% (F=89.0, P<0.001) of the variance in the LEMOCOT scores. When tonus of the plantar flexor muscles and age were included in the model, the explained variance increased to 54% (F=42.0, P<0.001). Lower limb motor recovery was positively associated with the LEMOCOT scores, whereas the tonus of the plantar flexor muscles and age were negatively correlated.

CONCLUSIONS

Motor recovery of the lower limb, tonus of the plantar flexor muscles, and age were significant predictors of MC of the paretic lower limb.

CLINICAL REHABILITATION IMPACT

These findings could help rehabilitation professionals to evaluate MC deficits and plan interventions aimed at improving MC of the lower limbs for stroke subjects, based upon the knowledge of the possible factors that could contribute to MC impairments.

Relationships between self-reported and performance-based measures of functional capacity in individuals with chronic stroke

[Purpose] The aim of this study was to investigate the associations between self-reported and valid performance-based measures of functional capacity in individuals with chronic stroke. [Subjects and Methods] Self-reported measures of functional capacity of 31 individuals with chronic stroke were assessed by the Duke Activity Status Index scores, whereas performance-based measures were assessed by the distance covered (in meters) and oxygen consumption (relative oxygen consumption, in ml·kg⁻¹·min⁻¹) during the six-minute walking test. [Results] The subjects had a mean age of 58.6±13 years and a mean time since the onset of stroke of 28.3±15.1 months. They had a mean Duke Activity Status Index of 27.3±14.4, mean distance covered of 325.2±140.2 m, and mean relative oxygen consumption of 9.6±2.3 ml·kg⁻¹·min⁻¹. Significant, positive, and moderate to good correlation coefficients were found between the Duke Activity Status Index scores and the distance covered during the six-minute walking test (r=0.68). Significant, positive, and fair associations were also found between the Duke Activity Status Index scores and relative oxygen consumption values obtained during the six-minute walking test (r=0.45). [Conclusion] The findings of the present study support the clinical use of the Duke Activity Status Index as a tool to assist in clinical evaluations of functional capacity of individuals with chronic stroke.

Assessment of the measurement properties of the post stroke motor function instruments available in Brazil: a systematic review

BACKGROUND

While there are several instruments in Brazil that measure motor function in patients after stroke, it is unknown whether the measurement properties of these instruments are appropriate.

OBJECTIVE

To identify the motor function instruments available in Brazil for patients after stroke. To assess the methodological quality of the studies and the results related to the measurement properties of these instruments.

METHOD

Two independent reviewers conducted searches on PubMed, LILACS, CINAHL, Web of Science, and Scopus. Studies that aimed to cross-culturally adapt an existing instrument or create a Brazilian instrument and test at least one measurement property related to motor function in patients after stroke were included. The methodological quality of these studies was checked by the COSMIN checklist with 4-point rating scale and the results of the measurement properties were analyzed by the criteria developed by Terwee et al.

RESULTS

A total of 11 instruments were considered eligible, none of which were created in Brazil. The process of cross-cultural adaptation was inadequate in 10 out of 11 instruments due to the lack of back-translation or due to inappropriate target population. All of the instruments presented flaws in the measurement properties, especially reliability, internal consistency, and construct validity.

CONCLUSION

The flaws observed in both cross-cultural adaptation process and testing measurement properties make the results inconclusive on the validity of the available instruments. Adequate procedures of cross-cultural adaptation and measurement properties of these instruments are strongly needed.

Prevention of Low Back Pain: A Systematic Review and Meta-analysis

IMPORTANCE

Existing guidelines and systematic reviews lack clear recommendations for prevention of low back pain (LBP).

OBJECTIVE

To investigate the effectiveness of interventions for prevention of LBP.

DATA SOURCES

MEDLINE, EMBASE, Physiotherapy Evidence Database Scale, and Cochrane Central Register of Controlled Trials from inception to November 22, 2014.

STUDY SELECTION

Randomized clinical trials of prevention strategies for nonspecific LBP.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed the risk of bias. The Physiotherapy Evidence Database Scale was used to evaluate the risk-of-bias. The Grading of Recommendations Assessment, Development, and Evaluation system was used to describe the quality of evidence.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was an episode of LBP, and the secondary outcome measure was an episode of sick leave associated with LBP. We calculated relative risks (RRs) and 95% CIs using random-effects models.

RESULTS

The literature search identified 6133 potentially eligible studies; of these, 23 published reports (on 21 different randomized clinical trials including 30,850 unique participants) met the inclusion criteria. With results presented as RRs (95% CIs), there was moderate-quality evidence that exercise combined with education reduces the risk of an episode of LBP (0.55 [0.41-0.74]) and low-quality evidence of no effect on sick leave (0.74 [0.44-1.26]). Low- to very low-quality evidence suggested that exercise alone may reduce the risk of both an LBP episode (0.65 [0.50-0.86]) and use of sick leave (0.22 [0.06-0.76]). For education alone, there was moderate- to very low-quality evidence of no effect on LBP (1.03 [0.83-1.27]) or sick leave (0.87 [0.47-1.60]). There was low- to very low-quality evidence that back belts do not reduce the risk of LBP episodes (1.01 [0.71-1.44]) or sick leave (0.87 [0.47-1.60]). There was low-quality evidence of no protective effect of shoe insoles on LBP (1.01 [0.74-1.40]).

CONCLUSION AND RELEVANCE

The current evidence suggests that exercise alone or in combination with education is effective for preventing LBP. Other interventions, including education alone, back belts, and shoe insoles, do not appear to prevent LBP. Whether education, training, or ergonomic adjustments prevent sick leave is uncertain because the quality of evidence is low.

Assessment of grip strength with the modified sphygmomanometer test: association between upper limb global strength and motor function

BACKGROUND

Grip strength, commonly evaluated with the handgrip dynamometer, is a good indicator of upper limb (UL) function in stroke subjects and may reflect the global strength deficits of the whole paretic UL. The Modified Sphygmomanometer Test (MST) also provides objective and adequate measures at low-cost.

OBJECTIVE

To assess whether grip strength values obtained by using the MST and those obtained by using a handgrip dynamometer would present similar correlations with the global strength and motor function of the paretic UL in subjects with stroke, both in the subacute and chronic phases.

METHOD

Measures of grip strength (MST and handgrip dynamometer), UL global strength (MST and hand-held dynamometer), and UL motor function (Fugl-Meyer motor assessment scale) were obtained with 33 subacute and 44 chronic stroke subjects. Pearson and Spearman correlation coefficients were calculated and Stepwise multiple regression analyses were performed to investigate predictor variables of grip strength (α=0.05).

RESULTS

Significant correlations of similar magnitude were found between measures of global strength of the paretic UL and grip strength assessed with both the MST (0.66≤r≤0.78) and handgrip dynamometer (0.66≤r≤0.78) and between UL motor function and grip strength assessed with both the MST (0.50≤rs≤0.51) and hand-held dynamometer (0.50≤rs≤0.63) in subacute and chronic stroke subjects. Only global strength remained as a significant predictor variable of grip strength for the MST (0.43≤R2≤0.61) and for the handgrip dynamometer (0.44≤R2≤0.61) for both stroke subgroups.

CONCLUSION

Grip strength assessed with the MST could be used to report paretic UL global strength.

Influences of hand dominance on the maintenance of benefits after home-based modified constraint-induced movement therapy in individuals with stroke

Objective:

To investigate the influence of hand dominance on the maintenance of gains after home-based modified constraint-induced movement therapy (mCIMT).

Method:

Aprevious randomized controlled trial was conducted to examine the addition of trunk restraint to the mCIMT. Twenty-two chronic stroke survivors with mild to moderate motor impairments received individual home-based mCIMT with or without trunk restraints, five times per week, three hours daily over two weeks. In this study, the participants were separated into dominant group, which had their paretic upper limb as dominant before the stroke (n=8), and non-dominant group (n=14) for analyses. The ability to perform unimanual tasks was measured by the Wolf Motor Function Test (WMFT) and the Motor Activity Log (MAL), whereas the capacity to perform bimanual tasks was measured using the Bilateral Activity Assessment Scale (BAAS).

Results:

Analysis revealed significant positive effects on the MAL amount of use and quality of the movement scales, as well as on the BAAS scores after intervention, with no differences between groups. Both groups maintained the bimanual improvements during follow-ups (BAAS-seconds 0.1, 95% CI -10.0 to 10.0), however only the dominant group maintained the unilateral improvements (MAL-amount of use: 1.5, 95% CI 0.7 to 2.3; MAL-quality: 1.3, 95% CI 0.5 to 2.1).

Conclusions:

Upper limb dominance did not interfere with the acquisition of upper limb skills after mCIMT. However, the participants whose paretic upper limb was dominant demonstrated better abilities to maintain the unilateral gains. The bilateral improvements were maintained, regardless of upper limb dominance.

Content validation of a clinical assessment instrument for stair ascent and descent in individuals with hemiparesis

BACKGROUND

Among the current instruments used to assess stair ambulation, none were observed that specifically evaluated the quality of movement or biomechanical strategies adopted by stroke patients.

OBJECTIVE

To evaluate the content validity of a clinical instrument designed to identify the qualitative and kinematic characteristics and strategies adopted by stroke patients during stair ascent and descent.

METHOD

The first developed version, which comprised 80 items, had its content evaluated by an expert panel, which was composed of 9 well-known national and international professionals who are involved in stroke rehabilitation. The content validity index (CVI) and modified Kappa coefficients were employed for the statistical analyses. The items that demonstrated a CVI≥0.80 and Kappa≥0.75 were considered valid.

RESULTS

The content validation was performed in three stages. The final version of the instrument consisted of 38 items, which were divided into descriptive (8 items), a General Characteristics Domain (16 items) and adopted strategies (14 items) during stair ascent and descent. The total scores ranged from zero to 70 and zero to 74 for ascent and descent, respectively. Lower scores corresponded with better performance.

CONCLUSION

Despite the satisfactory results obtained during the process of content validation, other psychometric properties of the instrument are necessary and must be evaluated.

Strength deficits of the shoulder complex during isokinetic testing in people with chronic stroke

OBJECTIVES

To examine the strength deficits of the shoulder complex after stroke and to characterize the pattern of weakness according to type of movement and type of isokinetic parameter.

METHOD

Twelve chronic stroke survivors and 12 age-matched healthy controls had their shoulder strength measured using a Biodex isokinetic dynamometer. Concentric measures of peak torque and work during shoulder movements were obtained in random order at speeds of 60°/s for both groups and sides. Type of movement was defined as scapulothoracic (protraction and retraction), glenohumeral (shoulder internal and external rotation) or combined (shoulder flexion and extension). Type of isokinetic parameter was defined as maximum (peak torque) or sustained (work). Strength deficits were calculated using the control group as reference.

RESULTS

The average strength deficit for the paretic upper limb was 52% for peak torque and 56% for work. Decreases observed in the non-paretic shoulder were 21% and 22%, respectively. Strength deficit of the scapulothoracic muscles was similar to the glenohumeral muscles, with a mean difference of 6% (95% CI -5 to 17). Ability to sustain torque throughout a given range of motion was decreased as much as the peak torque, with a mean difference of 4% (95% CI -2 to 10).

CONCLUSIONS

The findings suggest that people after stroke might benefit from strengthening exercises directed at the paretic scapulothoracic muscles in addition to exercises of arm elevation. Clinicians should also prescribe different exercises to improve the ability to generate force and the ability to sustain the torque during a specific range of motion.

Inspiratory muscular weakness is most evident in chronic stroke survivors with lower walking speeds

BACKGROUND

Respiratory muscular weakness and associated changes in thoracoabdominal motion have been poorly studied in stroke subjects, since the individuals' functional levels were not previously considered in the investigations.

AIM

To investigate the breathing patterns, thoracoabdominal motion, and respiratory muscular strength in chronic stroke subjects, who were stratified into two groups, according to their walking speeds.

DESIGN

Cross-sectional, observational study.

SETTING

University laboratory.

POPULATION

Eighty-nine community-dwelling chronic stroke subjects

METHODS

The subjects, according to their gait speeds, were stratified into community (gait speed ≥0.8 m/s) and non-community ambulators (gait speed <0.8 m/s). Variables related to pulmonary function, breathing patterns, and thoracoabdominal motions were assessed. Measures of maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were obtained and were compared with the reference values for the Brazilian population. The MIP and MEP values were expressed as percentages of the predicted values. Mann-Whitney-U or independent Student t-tests were employed to compare the differences between the two groups for the selected variables.

RESULTS

No significant between-group differences were found for the variables related to the breathing patterns and thoracoabdominal motions (0.01 < z/t < 1.51; 0.14<P<0.99). Compared to the predicted values, the stroke subjects demonstrated decreases of 26.5 and 20% of the MIP and MEP, respectively. Non-community ambulators showed significant lower predicted MIP values than those from the community ambulators (t=2.10; P=0.04). However, no significant between-group differences were found for the predicted MEP measures (t = -1.10; P=0.25).

CONCLUSION

Stroke subjects demonstrated weakness of the respiratory muscles and lower predicted MIP values were found for the non-community ambulators.

CLINICAL REHABILITATION IMPACT

Evaluations and interventions involving respiratory muscular training could be included in stroke rehabilitation, especially for individuals with lower functional levels.

Assessment of muscular strength with the modified sphygmomanometer test: what is the best method and source of outcome values?

Background

Tests that are usually employed for the clinical assessment of muscular strength have notable disadvantages. The Modified Sphygmomanometer Test (MST) is a promising method because it is low-cost and provides objective measures.

Objectives

To investigate the most adequate method and sources of outcome values for the assessment of strength with the MST.

Method

Methodological study with 40 healthy adults (22.98±2.26 years), who did not practice physical activity regularly. The strength of the flexors and extensors of the elbow and knee, the handgrip of the dominant side and anterior trunk flexors were randomly assessed with portable dynamometers and the MST (bag and cuff adaptations, and sphygmomanometer without adaptation) by a single examiner. An independent examiner read and recorded the values. The sources of the investigated outcome values were the first trial and the means of two and three trials. One-way ANOVAs and Pearson Correlation Coefficients were used for the analyses (α=0.05).

Results

For the MST methods applied to assess all muscular groups, similar values were found for all sources of outcome values (0.01<F<0.26; 0.77<p<1.00) with significant and positive correlations between the measures obtained with the dynamometers (0.51<r<0.94; p<0.003).

Conclusions

All MST methods showed adequate results for the assessment of strength in healthy individuals, and after familiarization, only one trial was sufficient to provide reliable measures. The sphygmomanometer without adaptation is not time consuming, compared to the other adaptations, and showed the capability of measuring higher values of strength. The bag method was easily trained to be used and stabilized.

Cyclical electrical stimulation increases strength and improves activity after stroke: a systematic review

QUESTION

Does electrical stimulation increase strength after stroke and are any benefits maintained beyond the intervention period or carried over to activity?

DESIGN

Systematic review with meta-analysis of randomised or controlled trials.

PARTICIPANTS

Adults who have had a stroke.

INTERVENTION

Cyclical electrical stimulation applied in order to increase muscle strength.

OUTCOME MEASURES

Strength measures had to be representative of maximum voluntary contraction and were obtained as continuous measures of force or torque, or ordinal measures such as manual muscle tests. Activity was measured using direct measures of performance that produced continuous or ordinal data, or with scales that produced ordinal data.

RESULTS

Sixteen trials representing 17 relevant comparisons were included in this systematic review. Effect sizes were calculated as standardised mean differences because various muscles were studied and different outcome measures were used. Overall, electrical stimulation increased strength by a standardised mean difference (SMD) of 0.47 (95% CI 0.26 to 0.68) and this effect was maintained beyond the intervention period (SMD 0.33, 95% CI 0.07 to 0.60). Electrical stimulation also improved activity (SMD 0.30, 95% CI 0.05 to 0.56) and this effect was also maintained beyond the intervention period (SMD 0.38, 95% CI 0.09 to 0.66).

CONCLUSION

Cyclical electrical stimulation increases strength and improves activity after stroke. These benefits were maintained beyond the intervention period with a small-to-moderate effect size. The sustained effect on activity suggests that the benefits were incorporated into daily life. Review registration: PROSPERO (CRD42013003895).

The addition of functional task-oriented mental practice to conventional physical therapy improves motor skills in daily functions after stroke

BACKGROUND

Mental practice (MP) is a cognitive strategy which may improve the acquisition of motor skills and functional performance of athletes and individuals with neurological injuries.

OBJECTIVE

To determine whether an individualized, specific functional task-oriented MP, when added to conventional physical therapy (PT), promoted better learning of motor skills in daily functions in individuals with chronic stroke (13 ± 6.5 months post-stroke).

METHOD

Nine individuals with stable mild and moderate upper limb impairments participated, by employing an A1-B-A2 single-case design. Phases A1 and A2 included one month of conventional PT, and phase B the addition of MP training to PT. The motor activity log (MAL-Brazil) was used to assess the amount of use (AOU) and quality of movement (QOM) of the paretic upper limb; the revised motor imagery questionnaire (MIQ-RS) to assess the abilities in kinesthetic and visual motor imagery; the Minnesota manual dexterity test to assess manual dexterity; and gait speed to assess mobility.

RESULTS

After phase A1, no significant changes were observed for any of the outcome measures. However, after phase B, significant improvements were observed for the MAL, AOU and QOM scores (p<0.0001), and MIQ-RS kinesthetic and visual scores (p=0.003; p=0.007, respectively). The significant gains in manual dexterity (p=0.002) and gait speed (p=0.019) were maintained after phase A2.

CONCLUSIONS

Specific functional task-oriented MP, when added to conventional PT, led to improvements in motor imagery abilities combined with increases in the AOU and QOM in daily functions, manual dexterity, and gait speed.

Treadmill training is effective for ambulatory adults with stroke: a systematic review

QUESTION

Does mechanically assisted walking increase walking speed or distance in ambulatory people with stroke compared with no intervention/non-walking intervention, or with overground walking?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Ambulatory adults with stroke.

INTERVENTION

Mechanically assisted walking (treadmill or gait trainer) without body weight support.

OUTCOME MEASURES

Walking speed measured in m/s during the 10-m Walk Test and walking distance measured in m during the 6-min Walk Test.

RESULTS

Nine studies of treadmill training comprising 977 participants were included. Treadmill training resulted in faster walking than no intervention/non-walking intervention immediately after the intervention period (MD 0.14m/s, 95% CI 0.09 to 0.19) and this was maintained beyond the intervention period (MD -0.12m/s, 95% CI 0.08 to 0.17). It also resulted in greater walking distance immediately after the intervention period (MD 40m, 95% CI 27 to 53) and this was also maintained beyond the intervention period (MD 40m, 95% CI 24 to 55). There was no immediate, statistically significant difference between treadmill training and overground training in terms of walking speed (MD 0.05m/s, 95% CI 0.12 to 0.21) or distance (MD -6m, 95% CI -45 to 33).

CONCLUSION

This systematic review provides evidence that, for people with stroke who can walk, treadmill training without body weight support results in faster walking speed and greater distance than no intervention/ non-walking intervention and the benefit is maintained beyond the training period.

Challenges in recruitment, attendance and adherence of acute stroke survivors to a randomized trial in Brazil: a feasibility study

BACKGROUND

There is a high demand for stroke rehabilitation in the Brazilian public health system which should make undertaking clinical trials straightforward.

OBJECTIVES

The aims of this study were to 1) determine the rate of recruitment of community-dwelling stroke survivors into a randomized trial of the effects of strength training in addition to task-specific gait training, 2) compare the effectiveness of various recruitment strategies on accrual rates, and 3) determine the attendance at training sessions and adherence to the intervention protocol.

METHODS

Participants within six months of a stroke were screened for eligibility and invited to participate. Recruitment strategies were classified as advertisement or referral. The number of people who were screened, eligible and recruited for each strategy was recorded. Attendance at training sessions and adherence to the intervention protocol were recorded.

RESULTS

Over the first 14 months, 150 stroke survivors were screened, 10 were recruited, and 35 (23%) were eligible. Twenty-five of these patients (71%) were unable to participate with lack of transport given as the most common reason. The most successful strategy was referral via hospital-based physical therapists (50%). Overall attendance was 72% with lack of transport being the most common reason for non-attendance. Overall adherence to the protocol was 97% with feeling unwell being the most common reason for non-adherence.

CONCLUSIONS

Recruitment of stroke survivors was inefficient. Lack of transport was the most common barrier to participate in and attend training sessions. Funding for transport is essential to make carrying out trials in Brazil feasible. Trial Registration ACTRN12609000803291.

Comparisons of the Nottingham Health Profile and the SF-36 health survey for the assessment of quality of life in individuals with chronic stroke

BACKGROUND

Appropriate instruments for the assessment of health-related quality of life (HRQOL) domains are useful for planning therapeutic interventions for individuals with stroke. The generic quality of life (QOL) instruments, Short Form Health Survey-36 (SF-36) and Nottingham Health Profile (NHP), have been frequently employed in the Brazilian literature. However, the literature is still scarce regarding their psychometric properties when applied to stroke individuals.

OBJECTIVES

To compare the Brazilian versions of the SF-36 and the NHP to verify which had better psychometric properties for the assessment of HRQOL in 120 individuals with chronic stroke.

METHOD

Spearman correlation coefficients were calculated to examine the comparable domains and total scores of the SF-36 and the NPH; Cronbach's alpha coefficients, to evaluate internal consistency; intra-class correlation coefficients, to assess reliability; and Bland-Altman plots, to assess the levels of agreement, with a significance level of 5%.

RESULTS

Significant positive associations were observed between the common domains and the total scores of the SF-36 and the NPH. Ceiling effects were more frequent for the NPH. The total scores of both instruments achieved adequate reliability levels, and the agreement levels were within the normal limits in 95% of the cases.

CONCLUSIONS

The SF-36 and the NPH were shown to measure similar constructs and proved to be useful measures for the assessment of QOL of chronic stroke subjects. However, the SF-36 yielded better results and appeared to be more appropriate.