Short-term and long-term effects of a progressive resistance and balance exercise program in individuals with chronic stroke: a randomized controlled trial

The effect of exercise interventions on reducing the risk of depressive and cognitive disorders in post-stroke-a systematic review and meta-analysis

Background

Stroke patients often experience sequelae such as depressive symptoms, cognitive impairment, and abnormal physical function. Exercise intervention may be an effective and safe non-drug treatment to address these health issues.

Objective

The aim of this meta-analytical review was to explore the effects of exercise intervention programs on depressive symptoms, cognitive function, physical function, and quality of life in stroke patients, as well as to identify appropriate exercise programs.

Methods

Seven databases were searched from the library's construction until 30 August 2024. A meta-analysis was performed, and the risk of bias was assessed using Review Manager 5.4. Sensitivity analysis was conducted using Stata 16.0 software, and the overall certainty of the evidence was rated using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methods.

Results

A total of 11,607 studies were identified. Among these, 20 studies, which included 1,848 patients, were considered eligible for this network meta-analysis. Compared to the control group, exercise significantly improved cognitive function (standard mean difference [SMD] = 1.08, 95% confidence interval [CI] = 0.40-1.75, p = 0.002), physical balance ability (mean difference [MD] = 0.80, 95% CI = 0.23-1.37, p < 0.01), physical walking ability (MD = 48.39, 95% CI = 8.06-88.72, p = 0.02), and quality of life. However, exercise had no significant effect on depressive symptoms (SMD = -0.2, 95% CI = -0.46-0.05, p = 0.11). A subgroup analysis indicated that a longer duration of exercise (> 3 months) can effectively improve depressive symptoms in stroke patients.

Conclusion

The results indicated that cognitive function, balance, walking speed, and quality of life of stroke patients improved following exercise intervention, and longer exercise duration (> 3 months) contributed to alleviating the depressive symptoms of stroke patients. Therefore, we recommend that stroke patients engage in physical exercise 3 times a week for 1 h each session. The exercise duration should continue for at least 3 months to ensure the best therapeutic effect. Furthermore, determining exercise intensity should be a personalized process-carefully customized to align with the physical capabilities and limitations of each patient.

Systematic review registration

https://www.crd.york.ac.uk/prospero, CRD42024520778.

Non-pharmacological interventions to treat mood disturbances post-stroke: a systematic review

BACKGROUND

Stroke survivors face high rates of depression, anxiety, and pseudobulbar affect. Clinicians report lack of clarity on effective non-pharmacological interventions due to uncertainty about treatment options as barriers to evidence-based treatment. No systematic review has investigated the effectiveness of non-pharmacological interventions on the conditions of depression, anxiety, and pseudo-bulbar affect.

OBJECTIVES

The aim of this study was to evaluate the effectiveness of non-pharmacological interventions on the outcomes of depression, anxiety, and pseudobulbar affect in post-stroke individuals.

METHODS

Following the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched databases Medline, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO for randomized controlled trials in English, within 2012-2023, evaluating the effect of a non-pharmacological intervention on depression, anxiety, and/or pseudobulbar affect. Two researchers screened titles, abstracts, and full texts. One researcher extracted data and assessed risk of bias. Data were synthesized narratively.

RESULTS

Forty-two studies were included. Intervention types included education (n = 9), psychological therapy (n = 8), and physical exercise (n = 8). Intervention types reporting positive outcomes for depression were psychological therapy (n = 6), physical exercise (n = 3) and robot-assisted therapy (n = 3). Intervention types effective in improving anxiety were physical exercise (n = 2), psychological therapy (n = 3) and multi-modal therapy approaches (n = 2). No studies explored the impact on pseudobulbar affect.

CONCLUSION

Non-pharmacological interventions may be effective in improving mood in stroke survivors. Robot-assisted therapy and physical exercise were seen to improve multiple outcome measures. Patient education should be delivered alongside rehabilitation and directed to both stroke-survivor and caregiver.

Comparative Effectiveness of Exercise on Cardiorespiratory Function or Exercise Efficiency After Stroke: A Network Meta-analysis of Randomized Control Trials

OBJECTIVE

The network meta-analysis was to compare and rank the effectiveness of different exercises on cardiorespiratory function or exercise efficiency in poststroke patients.

DESIGN

A network meta-analysis of randomized controlled trials was conducted. PubMed, Embase, Cochrane Library, and Web of Science were searched. The impact of exercises including individual and combination of aerobic exercise, resistance exercise, task-oriented training, gait training, breathing exercise, and regular rehabilitation training on 6-min walk test, peak oxygen consumption, maximum oxygen consumption, resting heart rate, resting systolic blood pressure, and resting diastolic blood pressure were assessed.

RESULTS

In total, 36 studies were included in the meta-analysis. Aerobic exercise + GT (63.06%) had the highest likelihood of improving 6-min walk test performance in poststroke patients. Regular rehabilitation training + resistance exercise was the most favorable exercise in terms of 6-min walk test performance assessing by minimum clinically significant difference. Aerobic exercise + resistance exercise had the highest likelihood of improving peak oxygen consumption and reducing resting heart rate in poststroke patients.

CONCLUSION

Different types of exercise demonstrated the benefits of improving cardiorespiratory function in stroke patients. Further research is needed to determine the best exercise regimen to maximize the benefits of rehabilitation interventions for poststroke patients.

Effectiveness of an Exercise Therapy Program Based on Sports in Adults With Acquired Brain Injury: A Randomized Controlled Trial

OBJECTIVE

To examine the effects of a sport-based exercise therapy (ET) program combined with usual care (sET+UC) compared with usual care (UC) alone on health-related quality of life, upper limb motor control, functional capacity, mobility, balance, and physical activity participation in ambulant adults with acquired brain injury (ABI).

DESIGN

Single-blind, parallel-group, randomized controlled trial.

SETTING

Rehabilitation center.

PARTICIPANTS

Twenty-three adults with ABI (82.6% stroke; 17 men; mean age of 59.6±10.3y).

INTERVENTION

Participants received either sET+UC (n=11) or UC (n=12). The sET+UC group received sixteen 60-minute sessions of a sport-based ET program in addition to sixteen 60-minute sessions of UC, whereas the UC group attended UC only.

MAIN OUTCOME MEASURES

Primary outcome measures were health-related quality of life (Short Form-36 [SF-36]) and upper limb motor control (Fugl-Meyer Upper Extremity [FM-UE]), whereas the secondary included functional capacity (6-minute walk test and 10-meter walk test), mobility (timed Up and Go Test), balance (Berg Balance Scale), and physical activity participation (Global Physical Activity Questionnaire).

RESULTS

Significant differences were found in all outcome analyses at postintervention when comparing between groups. The sET+UC group showed significant improvements in both the physical (P=.027, r=.46) and mental component summary (P=.001, r=.71) of the SF-36 as well as FM-UE (P=.004, r=.60), with large effect sizes. In turn, all secondary outcomes were also significantly improved in this group (all P<.05 r>.05). In contrast, the UC group showed slight improvements in postintervention scores but did not reach significance in any of these measures.

CONCLUSIONS

This study shows that a sport-based ET program combined with UC can effectively improve all the aforementioned outcomes measures in ABI population. Further research with larger sample sizes and follow-up assessments is crucial to gain a more comprehensive understanding of the long-term effects of the intervention in this specific population.

Physical rehabilitation approaches for the recovery of function and mobility following stroke

BACKGROUND

Various approaches to physical rehabilitation to improve function and mobility are used after stroke. There is considerable controversy around the relative effectiveness of approaches, and little known about optimal delivery and dose. Some physiotherapists base their treatments on a single approach; others use components from several different approaches.

OBJECTIVES

Primary objective: To determine whether physical rehabilitation is effective for recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.

SECONDARY OBJECTIVE

To explore factors that may impact the effectiveness of physical rehabilitation approaches, including time after stroke, geographical location of study, intervention dose/duration, intervention provider, and treatment components. Stakeholder involvement: Key aims were to clarify the focus of the review, inform decisions about subgroup analyses, and co-produce statements relating to key implications.

SEARCH METHODS

For this update, we searched the Cochrane Stroke Trials Register (last searched November 2022), CENTRAL (2022, Issue 10), MEDLINE (1966 to November 2022), Embase (1980 to November 2022), AMED (1985 to November 2022), CINAHL (1982 to November 2022), and the Chinese Biomedical Literature Database (to November 2022).

SELECTION CRITERIA

Inclusion criteria: Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke.

EXCLUSION CRITERIA

RCTs of upper limb function or single treatment components.

PRIMARY OUTCOMES

measures of independence in activities of daily living (IADL) and motor function.

SECONDARY OUTCOMES

balance, gait velocity, and length of stay.

DATA COLLECTION AND ANALYSIS

Two independent authors selected studies according to pre-defined eligibility criteria, extracted data, and assessed the risk of bias in the included studies. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

In this review update, we included 267 studies (21,838 participants). Studies were conducted in 36 countries, with half (133/267) in China. Generally, studies were heterogeneous, and often poorly reported. We judged only 14 studies in meta-analyses as at low risk of bias for all domains and, on average, we considered 33% of studies in analyses of primary outcomes at high risk of bias. Is physical rehabilitation more effective than no (or minimal) physical rehabilitation? Compared to no physical rehabilitation, physical rehabilitation may improve IADL (standardised mean difference (SMD) 1.32, 95% confidence interval (CI) 1.08 to 1.56; 52 studies, 5403 participants; low-certainty evidence) and motor function (SMD 1.01, 95% CI 0.80 to 1.22; 50 studies, 5669 participants; low-certainty evidence). There was evidence of long-term benefits for these outcomes. Physical rehabilitation may improve balance (MD 4.54, 95% CI 1.36 to 7.72; 9 studies, 452 participants; low-certainty evidence) and likely improves gait velocity (SMD 0.23, 95% CI 0.05 to 0.42; 18 studies, 1131 participants; moderate-certainty evidence), but with no evidence of long-term benefits. Is physical rehabilitation more effective than attention control? The evidence is very uncertain about the effects of physical rehabilitation, as compared to attention control, on IADL (SMD 0.91, 95% CI 0.06 to 1.75; 2 studies, 106 participants), motor function (SMD 0.13, 95% CI -0.13 to 0.38; 5 studies, 237 participants), and balance (MD 6.61, 95% CI -0.45 to 13.66; 4 studies, 240 participants). Physical rehabilitation likely improves gait speed when compared to attention control (SMD 0.34, 95% CI 0.14 to 0.54; 7 studies, 405 participants; moderate-certainty evidence). Does additional physical rehabilitation improve outcomes? Additional physical rehabilitation may improve IADL (SMD 1.26, 95% CI 0.82 to 1.71; 21 studies, 1972 participants; low-certainty evidence) and motor function (SMD 0.69, 95% CI 0.46 to 0.92; 22 studies, 1965 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up. Additional physical rehabilitation may improve balance (MD 5.74, 95% CI 3.78 to 7.71; 15 studies, 795 participants; low-certainty evidence) and gait velocity (SMD 0.59, 95% CI 0.26 to 0.91; 19 studies, 1004 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up. Is any one approach to physical rehabilitation more effective than any other approach? Compared to other approaches, those that focus on functional task training may improve IADL (SMD 0.58, 95% CI 0.29 to 0.87; 22 studies, 1535 participants; low-certainty evidence) and motor function (SMD 0.72, 95% CI 0.21 to 1.22; 20 studies, 1671 participants; very low-certainty evidence) but the evidence in the latter is very uncertain. The benefit was sustained long-term. The evidence is very uncertain about the effect of functional task training on balance (MD 2.16, 95% CI -0.24 to 4.55) and gait velocity (SMD 0.28, 95% CI -0.01 to 0.56). Compared to other approaches, neurophysiological approaches may be less effective than other approaches in improving IADL (SMD -0.34, 95% CI -0.63 to -0.06; 14 studies, 737 participants; low-certainty evidence), and there may be no difference in improving motor function (SMD -0.60, 95% CI -1.32 to 0.12; 13 studies, 663 participants; low-certainty evidence), balance (MD -0.60, 95% CI -5.90 to 6.03; 9 studies, 292 participants; low-certainty evidence), and gait velocity (SMD -0.17, 95% CI -0.62 to 0.27; 16 studies, 630 participants; very low-certainty evidence), but the evidence is very uncertain about the effect on gait velocity. For all comparisons, the evidence is very uncertain about the effects of physical rehabilitation on adverse events and length of hospital stay.

AUTHORS' CONCLUSIONS

Physical rehabilitation, using a mix of different treatment components, likely improves recovery of function and mobility after stroke. Additional physical rehabilitation, delivered as an adjunct to 'usual' rehabilitation, may provide added benefits. Physical rehabilitation approaches that focus on functional task training may be useful. Neurophysiological approaches to physical rehabilitation may be no different from, or less effective than, other physical rehabilitation approaches. Certainty in this evidence is limited due to substantial heterogeneity, with mainly small studies and important differences between study populations and interventions. We feel it is unlikely that any studies published since November 2022 would alter our conclusions. Given the size of this review, future updates warrant consensus discussion amongst stakeholders to ensure the most relevant questions are explored for optimal decision-making.

Prescribing strength training for stroke recovery: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To examine the effects of strength training on patient-important outcomes of stroke recovery and to quantify the influence of the exercise prescription on treatment effects.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Eight electronic databases (MEDLINE, EMBASE, EMCARE, AMED, PsycINFO, CINAHL, SPORTDiscus, and Web of Science) and two clinical trial registries (ClinicalTrials.gov and WHO International Clinical Trials Registry Platform) were searched from inception to 19 June 2024.

ELIGIBILITY CRITERIA

Randomised controlled trials were eligible if they examined the effects of strength training compared with no exercise or usual care and reported at least one exercise prescription parameter. An advisory group of community members with lived experience of stroke helped inform outcomes most relevant to stroke recovery.

RESULTS

Forty-two randomised trials (N=2204) were included. Overall risk of bias was high across most outcomes. Strength training improved outcomes rated as 'critical for decision-making' by the advisory group, including walking capacity (standardised mean difference (SMD)=0.95 (95% CI 0.34-1.56)), balance (SMD=1.13 (0.51-1.75)), functional ability and mobility (SMD=0.61 (0.09-1.14)), and habitual (mean difference (MD)=0.05 m/s (0.02-0.09)) and fast-paced walking speed (MD=0.09 m/s (0.01-0.17)), with very low to moderate certainty of evidence, mainly due to risk of bias and inconsistency. More frequent strength training, traditional strength training programmes and power-focused intensities (ie, emphasis on movement velocity) were positively associated with walking capacity, health-related quality of life and fast-paced walking speed.

CONCLUSION

Strength training alone or combined with usual care improves stroke recovery outcomes that are important for decision-making. More frequent strength training, power-focused intensities and traditional programme designs may best support stroke recovery.

PROSPERO REGISTRATION NUMBER

CRD42023414077.

Healthcare professionals' knowledge and perceptions of post-stroke rehabilitation in the peripandemic period: an online cross-sectional survey

The COVID-19 pandemic has profoundly affected healthcare systems, particularly post-stroke rehabilitation centers. The elevated severity of strokes and delayed hospital admissions caused numerous hurdles to rehabilitation administration during the peri-pandemic period. This study surveyed healthcare professionals' knowledge and perceptions of post-stroke rehabilitation during this period. An online cross-sectional survey was administered from September 17, 2023 to February 23, 2024, utilizing the SurveyMonkey platform. The questionnaire included 30 questions addressing participant baseline characteristics, knowledge of definitions and experiences, post-stroke rehabilitation procedures, obstacles encountered during the peri-pandemic period, and the utilization of telerehabilitation. Only complete responses from health professionals were considered. This report utilized convenience sampling. Data were analyzed via descriptive statistics and chi-square tests, with a significance threshold of p < 0.05. A total of 79 health professionals, predominantly physiatrists, neurologists, and physiotherapists, from eight countries participated in the study. Over half of the participants (64.6%) indicated the existence of a dedicated department for post-stroke rehabilitation. Significant obstacles comprised an absence of advanced rehabilitative treatments (60.8%), inadequately skilled workers (50.6%), and restricted space for rehabilitation (46.8%). Telerehabilitation was regarded as a feasible option by 45.6% of participants; nonetheless, obstacles, including patients' telecommunication proficiency and the possibility of diagnostic inaccuracies, were acknowledged. Complementary therapies, such as music and dance therapy, received favorable evaluations from 67.1% to 63.3% of respondents, respectively. The pandemic reduced rehabilitation admissions due to infection concerns (75.9%) and increased multimorbidity cases among patients (48.1%). The study underscores the pandemic's negative effect on post-stroke rehabilitation, emphasizing the necessity for multidisciplinary, customized therapy and enhanced integration of telerehabilitation to overcome access barriers. Addressing obstacles regarding infrastructure, training, and access to advanced approaches, particularly in a post-pandemic context, is essential to improving rehabilitation outcomes.

The implementation of sex-and gender-based considerations in exercise-based randomized controlled trials in individuals with stroke: A cross-sectional study

Emerging evidence suggests that sex-and gender-based factors may influence responses to exercise post-stroke. The Sex and Gender Equity in Research (SAGER) guidelines (2016) published international standards for terminology and considerations for research design and trial reporting. The extent to which sex- and gender-based considerations have been implemented in stroke exercise trials is currently unknown. The objective of this cross-sectional study was to compare the proportion of studies that have implemented sex/gender considerations before and after the publication of the SAGER guidelines. We conducted a comprehensive search of the literature to identify exercise-based trials in individuals with stroke. Study titles, abstracts, introductions (hypothesis statements), methods, results and discussions were assessed for adherence to the SAGER guidelines. The proportion of studies adhering to SAGER guidelines published prior to and including December 31, 2016 and from 2017-March 2023 were compared. Of the 245 studies identified, 150 were published before December 31, 2016, of which 0 (0%) titles/abstracts, 0 (0%) introductions, 21 (14.0%) methods, 8 (5.3%) results, and 7 (4.7%) discussion sections adhered to the SAGER guidelines, and 35 (23.3%) reported proper sex and gender terminology. Of the 95 studies published between 2017-2023, 0 (0%) title/abstracts, 1 (1.0%) introduction, 16 (16.8%) methods, 5 (5.3%) results, and 10 (10.5%) discussion sections adhered to the guidelines, and 37 (38.9%) of studies included proper terminology. The implementation of sex- and gender-based considerations in stroke exercise trials is low, but positively the reporting of proper terminology has increased since the publication of standardized reporting guidelines. This study serves as a call to action for stroke rehabilitation researchers to incorporate sex- and gender-based considerations in all stages of research studies, to improve the rigour and generalizability of findings, and promote health equity.

The Role of Spirituality in Stroke Survivors and Their Caregivers: A Systematic Review

Although several studies have analyzed the effects of spirituality on stroke survivors' physical functioning and their caregiver's outcomes, no systematic review or meta-synthesis was found to identify the lived experiences of stroke survivors and caregivers regarding spirituality. For these reasons, this study aimed to analyze quantitively and qualitatively research relating to stroke survivors' and caregivers' experiences. The included studies were RCT studies, quasi-experimental studies, qualitative, descriptive, ethnographic, and phenomenological studies, and cross-sectional studies (n = 37), with a total of 6850 stroke survivors and 1953 caregivers enrolled. Spirituality appears to play an important role in improving the quality of life and decreasing anxiety and depression of both stroke survivors and their caregivers.

Non-pharmacological interventions on quality of life in stroke survivors: A systematic review and meta-analysis

BACKGROUND

Non-pharmacological interventions have been used in the rehabilitation of stroke survivors, but their effects on stroke survivors' quality of life (QoL) are unknown.

AIM

This review aimed to summarize the existing evidence regarding non-pharmacological interventions for QoL in stroke survivors and to evaluate the effectiveness of different types of interventions.

METHODS

We systematically searched databases including PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Chinese BioMedical Literature Database, China Science and Technology Journal Database, and Wanfang data from the earliest available records to March 2023. Randomized controlled trials which explored the effects of non-pharmacological interventions on QoL in stroke patients were included. The meta-analysis was conducted to evaluate the effectiveness of different interventions on QoL. The Review Manager 5.3 was used to conduct the meta-analysis and the revised Cochrane risk-of-bias tool was used to assess the methodological quality of trials.

RESULTS

A total of 93,245 records were identified, and 34 articles were reviewed and summarized, of which 20 articles were included in the meta-analysis. The summary of the findings of the included studies revealed fitness training, constraint-induced movement therapy (CIMT), physical exercise, music therapy (MT), and art-based interventions may have positive effects on QoL. The fitness training improved total QoL, especially in physical domains including physical functioning (mean difference [MD] = 10.90; 95% CI [7.20, 14.59]), role physical (MD = 10.63; 95% CI [6.71, 14.55]), and global health (MD = 8.76; 95% CI [5.14, 12.38]). The CIMT had a slight effect on general QoL (standardized mean difference [SMD] = 0.48, 95% CI [0.16, 0.80]), whereas significantly improved strength (MD = 8.84; 95% CI [1.31, 16.38]), activities of daily living/instrumental activities of daily living (ADL/IADL; MD = 10.42; 95% CI [2.98, 17.87]), and mobility (MD = 8.02; 95% CI [1.21, 14.83]). MT had a positive effect on the mental health domain (SMD = 0.54; 95% CI [0.14, 0.94]).

LINKING EVIDENCE TO ACTION

Our findings suggest that fitness training and CIMT have a significant effect on improving physical QoL, while MT has a positive effect on improving psychological QoL. Future studies may use comprehensive and multicomponent interventions to simultaneously improve the patients' physical, psychological, and social QoL.

The immediate and lasting balance outcomes of clinical falls-prevention programs: A non-randomised study

PURPOSE

Exercise-based falls-prevention programs are cost-effective population-based approaches to reduce the risk of falling for older adults. The aim was to evaluate the short-term and long-term efficacy of three existing falls-prevention programs.

METHODS

A non-randomized study design was used to compare the immediate-post and long-term physical outcome measures for three falls prevention programs; one high-level land-based program, one low-level land-based program and a water-based Ai Chi program. Timed-up-and-go (TUG), five-times sit-to-stand (5xSTS), six-minute walk test (6MWT) and six-meter walk test were assessed at baseline, post-program, and at six-months follow-up. Linear mixed models were used to analyze between- and within- group differences, with the high-level land-based program used as the comparator.

RESULTS

Thirty-two participants completed post-program assessment and 26 returned for follow-up. There was a difference in the age (years) of participants between programs (p = 0.049). The intercept for TUG and six-meter walk test time was 47.70% (23.37, 76.83) and 32.31s (10.52, 58.41), slower for the low-level group and 40.49% (17.35, 69.89) and 36.34s (12.75, 64.87), slower for the Ai Chi group (p < 0.01), compared with the high-level group. Mean time taken to complete the TUG was less both immediately post-program and at 6-month follow-up (p = 0.05). Walking speed for the six-meter walk test was only faster at six-months (p < 0.05). The 5xSTS duration was significantly reduced only at post-intervention (p < 0.05).

CONCLUSION

These results indicate land-based and water-based falls-prevention programs improve physical outcome measures associated with falls-risk and many improvements are maintained for six months after the completion of the program. (Retrospective trial registration: ACTRN1262300119069).

Post-stroke rehabilitation in the peri-pandemic COVID-19 era

The coronavirus disease 2019 (COVID-19), which arose in late 2019, caused extensive destruction, impacting a substantial proportion of the worldwide population and leading to millions of deaths. Although COVID-19 is mainly linked to respiratory and pulmonary complications, it has the potential to affect neurologic structures as well. Neurological involvement may manifest as minimal and reversible; however, a notable proportion of cases have exhibited pronounced neurological consequences, such as strokes. Endothelial inflammation, hypercoagulation, renin-angiotensin-aldosterone system alterations, and cardiogenic embolism are the pathophysiological mechanisms of stroke under COVID-19 circumstances. Physical activity and exercise have improved several aspects of post-stroke recovery, including cardiovascular health, walking capacity, and upper limb strength. They are commonly used to assist stroke survivors in overcoming their motor restrictions. Furthermore, stroke rehabilitation can incorporate a range of specific techniques, including body-weight-supported treadmill applications, constraint-induced movement therapy, robotic rehabilitation interventions, transcranial direct current stimulation, transcranial magnetic stimulation, and prism adaptation training. Under pandemic conditions, there were several barriers to neurological rehabilitation. The most significant of these were individual's fear of infection, which caused them to postpone their rehabilitation applications and rehabilitation areas being converted into COVID-19 units. The primary emphasis had turned to COVID-19 treatment. Several valuable data and views were gained in reorganizing rehabilitation during the pandemic, contributing to establishing future views in this regard.

The effect of moderate and vigorous aerobic exercise training on the cognitive and walking ability among stroke patients during different periods: A systematic review and meta-analysis

OBJECTIVE

The study examined whether rehabilitation using aerobic exercise is more appropriate for patients less than 3 months post-stroke or more appropriate for patients more than 3 months post-stroke.

METHOD

PubMed, Embase, Web of Science, Scopus and CNKI databases were searched from inception to September 2023. All studies included must be written in English and grey literature was excluded. The quality of the study was evaluated using the PEDro scale. Standard mean difference (SMD) and 95% confidence interval (CI) were calculated. The primary outcomes are cognitive ability and walking ability. The intervention of the experimental group must be or include high-intensity aerobic training or moderate-intensity aerobic training. In addition, we required low intensity routine exercises in control group.

RESULT

Only 15 studies were included in this meta-analysis. The results showed that aerobic exercise has a positive rehabilitation effect on cognitive and walking ability of stroke patients. Global Cognitive Function (SMD = 0.81 95%CI 0.49-1.12), Walking Capacity (SMD = 1.19, 95%CI 0.75-1.62), VO2peak (SMD = 0.97, 95%CI 0.66-1.28), and brain-derived neurotrophic factor (SMD = 2.73, 95%CI 2.03-3.43). We further observed that patients who suffered a stroke within the past three months exhibited superior rehabilitation outcomes compared to patients who suffered a stroke more than three months ago, specifically in terms of cognitive ability, walking tests, and cardiopulmonary function.

CONCLUSIONS

It is recommended to carry out treatment for patients in the initial stage of stroke, and it is required to pay attention to exercise intensity in the process of treatment to ensure patient safety.

Impact of Active Physiotherapy on Physical Activity Level in Stroke Survivors: A Systematic Review and Meta-Analysis

BACKGROUND

Stroke survivors are frequently physically inactive. However, evidence of the effectiveness of active physiotherapy on physical activity level in stroke survivors is scarce.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, covering electronic searches from inception to March 16, 2022. Participants: Stroke survivors living in the community. Intervention: Any active physiotherapy, that is, involving exercises that require voluntary effort. Outcome measure: Objective and subjective physical activity level.

RESULTS

Of 5590 identified references, 25 randomized controlled trials were eligible, and 21 had available data. The random-effects meta-analysis resulted in a small, significant effect size in favor of active physiotherapy measured using objective or subjective tools (21 studies, 1834 participants, standardized mean difference, 0.22 [95% CI, 0.04-0.40]; heterogeneity I2=65%), and a medium significant effect when objective tools were used (9 studies, 424 participants, standardized mean differences, 0.48 [95% CI, 0.03-0.92]; I2=73%). Meta-regression showed that 35% of the variance in trial outcome was explained by the measurement tool (objective or subjective) and 23% by age. None of the variances were associated with a specific dosage in terms of frequency, time, exercise duration, or the severity of the disability.

CONCLUSIONS

Active physiotherapy seems to increase objective physical activity in community-dwelling stroke survivors. However, the evidence is of very low certainty.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42022315639.

Effects of multicomponent exercise on quality of life, depression and anxiety among stroke survivors: A systematic review and meta-analysis

BACKGROUND

Current guidelines stress the importance of exercise, especially multicomponent exercise to older adults with chronic conditions.

AIM

To critically synthesise evidence that evaluates the effects of multicomponent exercise on quality of life, depression and anxiety after stroke.

DESIGN

Systematic review and meta-analysis followed the PRISMA 2020 statement.

METHODS

A systematic search of PubMed, Embase, Web of Science, Cochrane Library, CINAHL and PsycINFO from inception to 12 June 2023 was performed. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2). Meta-analyses were conducted using Review Manager 5.4 and narrative syntheses were adopted whenever meta-analysis was inappropriate. The overall certainty of the evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Of 15,351 records identified, nine were eligible and data were available for seven randomised controlled trials, three of which were identified as having a high risk of bias, one as low risk, and five as having some concerns. Subgroup pooled analyses indicated that multicomponent exercise engaged in longer exercise sessions (>60 min) was effective in improving quality of life immediately post-intervention and through 3-6 months post-intervention. However, multicomponent exercise did not significantly affect depression and anxiety.

CONCLUSIONS

Multicomponent exercise with longer duration of exercise sessions has promising effects on both short- to medium-term quality of life among stroke survivors.

PATIENT OR PUBLIC CONTRIBUTION

This does not apply to our work as it is a review paper.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers could consider encouraging the patients to participate in multicomponent exercise sessions for more than 60 min. It is important to note that stroke survivors should be supervised by trained personnel at the beginning of the training.

REGISTRATION

The protocol was registered on PROSPERO.

Investigating the Combined Effects of Mechanical Stress and Nutrition on Muscle Hypertrophic Signals Using Contractile 3D-Engineered Muscle (3D-EM)

Since 3D-EM closely resembles in vivo muscles, the aim of this study was to investigate the effects of exercise (electrical pulse stimulation (EPS)) and nutrition (maca), which contains triterpenes, on muscle hypertrophy by using 3D-EM for the first time. The 3D-EM was composed of C2C12 cells and type 1 collagen gel, was differentiated for 14 days, and was divided into four groups: control, maca, EPS, and maca + EPS. The medium was replaced every two days before each EPS intervention, and the concentration of maca in the culture solution was 1 mg/mL. The intervention conditions of the EPS were 30 V, 1 Hz, and 2 ms (24 h on, 24 h off, for one week). The expression levels of proteins were examined by Western blotting. The intervention of maca and EPS upregulated the expression of MHC-fast/slow (both p < 0.05) compared with the control group, and the addition of maca had no effect on the phosphorylation of mTOR (p = 0.287) but increased the AMPK phosphorylation (p = 0.001). These findings suggest that intervention with maca and EPS has a positive effect on muscle hypertrophy, which has a positive impact on sarcopenia. However, the underlying mechanisms remain to be further explored.

Effects of health qigong exercise on upper extremity muscle activity, balance function, and quality of life in stroke patients

Introduction

This study explored the effects of Qigong exercises on upper extremity muscle activity, balance function, and quality of life in stroke patients.

Methods

A total of 30 stroke patients were randomly allocated to either control group or Qigong group. In the Qigong group, participants completed an intervention of Qigong Baduanjin over 8 weeks. Data on the electromyographic activities of the biceps brachii muscle, triceps brachii muscle, and muscle coordination were obtained using surface electromyography and the co-contraction ratio (CCR). Data on balance were obtained using the PK254P balance function detection system. Quality of life was measured using the brief version of the World Health Organization Quality of Life scale.

Results

The results for the Qigong group showed a significant difference in CCR of the triceps brachii muscle (p < 0.01). Concerning balance (assessed using the open-eye test), there was a significant decrease (p < 0.05) in Y-axis trajectory deviations and the Y-axis speed in the Qigong group. In the closed-eye test, the peripheral area of the Qigong group was significantly lower than that of the control group (p < 0.05). Significant differences were also observed in physical health (p < 0.05), psychological health (p < 0.01), environment (p < 0.01), and the total scores for quality of life (p < 0.01) in the Qigong group.

Discussion

We conclude that Qigong exercises improve the quality of life in stroke patients and have positive effects on the coordination of limb extremities and balance function.

The Effect of Diagonal Exercise Training for Neurorehabilitation on Functional Activity in Stroke Patients: A Pilot Study

Functional movements of the human body occur multifacetedly. This pilot study investigated the effects of neurorehabilitation training, including diagonal movements, balance, gait, fall efficacy, and activities of daily living in stroke patients. Twenty-eight patients diagnosed with stroke by a specialist were divided into experimental groups applying diagonal exercise training and control groups applying sagittal exercise training. The five times sit-to-stand test (FTSST), timed up and go (TUG) test, and Berg balance scale (BBS) were used to evaluate balance ability, the falls efficacy scale (FES) was used to evaluate fall efficacy, and the modified Barthel index (MBI) was used to evaluate activities of daily living. All evaluations were conducted once prior to intervention implementation and again six weeks after the final intervention. In the study results, the experimental group to which the diagonal exercise training was applied had statistically significant changes in FTSST, BBS, and FES compared to the control group. In conclusion, the rehabilitation program, including diagonal exercise training, increased the patient's balance and reduced the fear of falling.

Dosages of Swallowing Exercises Prescribed in Stroke Rehabilitation: A Medical Record Audit

This study investigated how swallowing exercise dosage is recorded, and what swallowing exercise dosages are reported in a stroke rehabilitation setting. We additionally explored the relation between mean daily swallowing repetitions and likelihood of improvement in functional swallowing status and considered how swallowing exercise dosages in practice compared to evidence-based principles of neural plasticity and strength training. We audited medical records for 42 patients with post-stroke dysphagia admitted to an inpatient rehabilitation unit over 18 months. Data were collected on participant characteristics, swallowing exercises and dosages, and clinical outcomes. The relation between dosage and outcomes was investigated using logistic regression analysis. On average, patients were seen for a median of 2.4 swallowing intervention sessions per week (IQR: 1.7) over 21 days (IQR: 16) and received a median 44.5 swallowing exercise repetitions per session (IQR: 39.6). Results indicated variable reporting of swallowing exercise dosages. Frequency, intervention duration, exercise type, and number of repetitions were routinely recorded in medical records, while intensity, session length, content, and adherence to home exercise programs were not. Frequency of swallowing intervention was lower in practice compared to research studies, and swallowing exercises did not follow specificity or progressive resistance principles. Likelihood of improvement in swallowing status was partially explained by age (B = -.015, p = .007) but not by mean daily swallowing exercise repetitions. This study illustrates dosages of swallowing exercises used in clinical practice. Results highlight the need for improved consideration and reporting of dosage, and application of evidence-based principles to swallowing exercise dosages.

Effect of physical exercise on fear of falling in patients with stroke: A systematic review and meta-analysis

OBJECTIVE

To consolidate the evidence on the effect of physical exercise on fear of falling in individuals with stroke.

DATA SOURCES

PubMed, CINAHL, Cochrane Database and MEDLINE.

METHODS

An extensive database search was conducted to identify the randomised controlled trials that examined the effect of physical exercise on fear of falling post-stroke. Grading of Recommendation, Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence for each meta-analysis.

RESULTS

Fourteen trials totalling 1211 participants were included in this review. Thirteen of these (1180 participants) were included in the meta-analyses. In the primary analysis, very low-quality evidence suggested that exercise reduced fear of falling post-stroke (standardized mean difference (SMD) 0.48; 95% confidence interval (CI) 0.23 to 0.72). The effect was diminished at three- to six-month follow-up after exercise training ended (SMD -0.09; 95% CI -0.27 to 0.10; high-quality evidence). In the sensitivity analyses, the treatment effect was more pronounced in individuals with a lower baseline Berg balance score (BBS ≤45; SMD 0.53; 95%CI 0.17 to 0.88) and for those trials with exercise frequency of ≥3 sessions per week (SMD 0.70; 95%CI 0.39 to 1.01). Compared with circuit-based training consisting of a combination of walking, balance and strengthening exercises (SMD 0.27; 95% CI -0.09 to 0.63), walking programmes seemed to generate a larger effect on fear of falling (SMD 1.06; 95%CI 0.43 to 1.70).

CONCLUSION

Physical exercise was beneficial for reducing fear of falling in individuals with stroke, particularly those with poorer balance ability.

Effect of Progressive Postural Control Exercise Versus Core Stability Exercise in Young Adults with Chronic Low Back Pain: A Randomized Controlled Trial

INTRODUCTION

This study aimed to investigate the effects of progressive postural control exercise (PPCE) vs core stability exercise (CSE) in patients with chronic low back pain (CLBP).

METHODS

A total of 34 young-adult participants with CLBP were randomly assigned to two groups (the PPCE group and the CSE group). They received instructions for two different exercise training regimens persisting over 8 weeks. Before, after, and at 6 months after the intervention, the participants were evaluated on the basis of pain intensity (VAS), degree of dysfunction (ODI and RMDQ), contractility of transversus abdominis (TrA) and lumbar multifidus (MF), as well as the ability to control static posture.

RESULTS

There was no significant difference between the results of the PPCE group and the CSE group. At the 6-month follow-up after the 8-week treatment, the scores of VAS, ODI, and RMDQ in the two groups decreased significantly compared to before (p < 0.05). The percentage change in thickness of bilateral TrA and left MF (p < 0.05) was elevated and the sway area of center of pressure during static stance tasks with eyes opened (p < 0.05) was decreased in both groups.

CONCLUSION

In the short term, PPCE provides positive effects similar to those of core stability exercise in patients with CLBP. The effective mechanism of PPCE might be the consequence of neuromuscular plasticity and adaptation adjustments. PPCE enriches the choices of treatment for CLBP.

CLINICAL TRIAL REGISTRATION

The trial was registered at www.chictr.org.cn , identifier ChiCTR2100043113.

Effects of Exercise Programs on Functional Capacity and Quality of Life in People With Acquired Brain Injury: A Systematic Review and Meta-Analysis

OBJECTIVE

The aims of this systematic review and meta-analyses were to evaluate the effects of exercise on the functional capacity and quality of life (QoL) of people with acquired brain injury (ABI) and to analyze the influence of training variables.

METHODS

Five electronic databases (MEDLINE, Cochrane Library, CINAHL, SportDiscus, and Web of Science) were searched until October 2021 for clinical trials or experimental studies examining the effects of exercise on the functional capacity and QoL in adults with ABI and comparing exercise interventions with non-exercise (usual care).

RESULTS

Thirty-eight studies were evaluated. A total sample of 2219 people with ABI (exercise, n = 1572; control, n = 647) were included in the quantitative analysis. A greater improvement was observed in walking endurance (z score = 2.84), gait speed (z score = 2.01), QoL physical subscale (z score = 3.42), and QoL mental subscale (z score = 3.00) was observed in the experimental group than in the control group. In addition, an improvement was also observed in the experimental group in the "Timed Up and Go" Test scores and balance without differences from the control group. Significant interactions were also observed between the rehabilitation phases, type, frequency and volume of training, and overall effects.

CONCLUSION

The results suggest that exercise improves functional capacity and QoL regardless of model training, highlighting the effectiveness of long-term exercise that includes short sessions with components such as strength, balance, and aerobic exercise.

IMPACT

The results shown in this systematic review with meta-analysis will allow physical therapists to better understand the effects of training on people with ABI.

Molecular mechanisms of exercise contributing to tissue regeneration

Physical activity has been known as an essential element to promote human health for centuries. Thus, exercise intervention is encouraged to battle against sedentary lifestyle. Recent rapid advances in molecular biotechnology have demonstrated that both endurance and resistance exercise training, two traditional types of exercise, trigger a series of physiological responses, unraveling the mechanisms of exercise regulating on the human body. Therefore, exercise has been expected as a candidate approach of alleviating a wide range of diseases, such as metabolic diseases, neurodegenerative disorders, tumors, and cardiovascular diseases. In particular, the capacity of exercise to promote tissue regeneration has attracted the attention of many researchers in recent decades. Since most adult human organs have a weak regenerative capacity, it is currently a key challenge in regenerative medicine to improve the efficiency of tissue regeneration. As research progresses, exercise-induced tissue regeneration seems to provide a novel approach for fighting against injury or senescence, establishing strong theoretical basis for more and more "exercise mimetics." These drugs are acting as the pharmaceutical alternatives of those individuals who cannot experience the benefits of exercise. Here, we comprehensively provide a description of the benefits of exercise on tissue regeneration in diverse organs, mainly focusing on musculoskeletal system, cardiovascular system, and nervous system. We also discuss the underlying molecular mechanisms associated with the regenerative effects of exercise and emerging therapeutic exercise mimetics for regeneration, as well as the associated opportunities and challenges. We aim to describe an integrated perspective on the current advances of distinct physiological mechanisms associated with exercise-induced tissue regeneration on various organs and facilitate the development of drugs that mimics the benefits of exercise.

Rationale and Feasibility of Resistance Training in hEDS/HSD: A Narrative Review

Hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD) are genetic conditions characterized by increased joint hypermobility, often in the presence of other signs or symptoms if syndromic. This hypermobility can result in significant pain and ultimately decreased participation in recreational or competitive activity. Rehabilitation of patients with hEDS/HSD is not well understood, particularly since presentation can be relatively heterogenous. Regardless, more research is needed, particularly regarding resistance training, to allow patients with hEDS/HSD to participate in the activities they enjoy. The purpose of this narrative review is to provide an overview of the clinical features displayed by those with hEDS/HSD that have been found to be improved with resistance training in other populations, and to present the current evidence for resistance training in all types of study designs, ranging from case studies to randomized controlled trials.

Community living after in-hospital specialized rehabilitation in patients with severe disability after stroke: a long-term follow-up after a randomized controlled trial

PURPOSE

Physical functioning after discharge from specialized rehabilitation is a concern. The purpose of this study was to investigate functioning and health after a long period of community living in participants with severe disability after stroke.

MATERIALS AND METHODS

An observational, longitudinal follow-up design was used to investigate 60 participants from a randomized controlled trial. Assessment tools: Short Form 36 health-survey, Functional Ambulation Categories, EU Walking, 10 Meter Walk Test, and questions concerning health and walking ability.

RESULTS

Forty-seven participants (78%) responded, mean age 51.2 years. Non-respondents demonstrated poorer function at hospital discharge. At follow-up, median 11.9 months after discharge, all but three respondents lived in their own home, and 85% received physiotherapy. Twenty-nine (64%) perceived their health as good to excellent, while four (9%) reported poor health. Activities requiring substantial strength and endurance were typically restricted. Most participants (83%) were independent walkers, and fewer (a 27% reduction) used a wheelchair. Among independent walkers, mean walking speed improved by 0.14 m/s. Time elapsed since hospital discharge was not found to correlate with change in walking speed.

CONCLUSIONS

This study demonstrates maintenance or progress in important aspects of functioning and health in most participants at long-term follow-up, but not in all.Implications for rehabilitationPatients with severe disability after stroke may maintain or improve their physical functioning and health after a long period of community living, when they receive continuous individualized rehabilitation including physiotherapy.Patients who maintain or improve walking ability and walking speed after living for a long time in the community, may still need assistance with daily activities, especially if they require substantial muscle strength and endurance.Expectations to long-term functional outcomes after institutional followed by community rehabilitation for patients after stroke, should be considered in light of functional status at hospital discharge.

Benefits of physical exercise programs toward people with acquired brain injury: A protocol for systematic review and meta-analysis

BACKGROUND

Exercise has proven to be a tool improving health related quality of life in people with acquired brain injury (ABI) as part of multidisciplinary team during the subacute and chronic phase. While intervention studies and revisions have been increased in recent years, there is no consensus about the type, frequency and variables of control in exercise interventions. Besides, this collective need programs that respond to different functional levels, given the heterogeneity of people with ABI, not only because of the etiology, but also because of the severity differences over their deficits. The aim of this systematic review and meta-analysis is to summarize the evidence regarding the relationship between exercise and health related quality of life in subacute and chronic phase.

METHODS

A protocol of systematic review and meta-analysis will examine the benefits of physical exercise (PE) toward people with ABI will be conducted. A comprehensive search will be conducted in the following electronic databases: MEDLINE, The Cochrane Library, CINAHL, SportDiscus, and Web of Science from inception to July 2020. Independent review authors will evaluate the title and abstract for each trial and disagreements will be solved by discussion with a third author if necessary. Standard pairwise meta-analysis, including heterogeneity analysis, subgroup analysis, and sensitivity analysis, will be performed using the Stata software. The quality evaluation of this study will be completed using the Cochrane collaboration risk of bias tool and the risk of bias assessment will be conducted by the World Health Organization grading of recommendations, assessment, development, and evaluation. The review will be reported in accordance to the preferred reporting items for systematic reviews and meta-analyses statement.

RESULTS AND CONCLUSSION

This systematic review and meta-analysis protocol will provide an overview regarding the benefits of PE on functioning, social participation and quality of life toward people with ABI. The variability of outcomes across PE from the selected studies will provide important information for future trial designs. Results of the proposed review will inform practice and the design of future clinical trials. This study will summarize all the selected trials aimed at estimating the effectiveness of applying physical activity programs to ABI users.Systematic review registration number: PROSPERO CRD42020191779.

Understanding Clinical Significance in Rehabilitation: A Primer for Researchers and Clinicians

ABSTRACT

The objective of this review was to summarize the concept of clinical significance and associated methods focusing on the area of rehabilitation to provide a resource to rehabilitation researchers and clinicians. Studies were searched on electronic databases from inception until July 28, 2020, with no date or language limits. Manual searches as well as Scopus forward citation for relevant references were performed. Narrative synthesis of study results was performed. Definitions of the concepts related to clinical significance, ways of calculating, and interpreting each method were provided using rehabilitation examples. An explanation of methods to evaluate clinical significance (distribution, anchor, and opinion-based methods) and their advantages and disadvantages were also provided. Considering the limitations of statistical significance in assuring meaningfulness of results, clinical interpretation of research outcomes and the report of clinical significance in intervention trials should be a priority in rehabilitation research. When possible, the use of multiple methods (distribution, anchor, and opinion based) is recommended. Thus, clinical researchers are encouraged to present results in a manner that allow the rehabilitation professionals to easily interpret and implement those results in their clinical practice.

Adaptive sports for promoting physical activity in community-dwelling adults with stroke: A feasibility study

BACKGROUND

Despite proven health benefits of regular participation in physical activities (PA), adults with stroke fail to achieve recommended levels of PA. Sports being an enjoyable activity is more likely to encourage participation. Therefore, the objectives of the present study are i) to develop and test the feasibility of adaptive sports for promoting PA and Quality of Life (QoL) in community-dwelling adults with stroke, and ii) to explore the participants perception and experiences of playing adaptive sports.

METHODS

Two focus groups were conducted among the eight experts and a person with stroke to develop adaptive sports. To test the feasibility of these adaptive sports, in a multi methods study eighteen community dwelling adults with stroke were recruited. Participants played adaptive sports twice a week for two months in a community center. Participants pre and post intervention PA levels and QoL were measured. Participants were also interviewed at the end of the program to explore their experiences of participation in adaptive sports.

RESULTS

At the end of the program retention rate of the participants was 83.33% and there was a significant improvement in PA levels, while the improvement in QoL was not statistically significant. Participants expressed positive experience with the program. There were no adverse events during or after the participation. Health benefits, fitness, and fun were reported as facilitators, while lack of access to the sporting facility and lack of caregiver support were reported as barriers to participation.

CONCLUSION

Adaptive sports appear to be safe, feasible, and well accepted by the adults with stroke.

Effects of Immersive and Non-Immersive Virtual Reality on the Static and Dynamic Balance of Stroke Patients: A Systematic Review and Meta-Analysis

(1) Background: The development of new technologies means that the use of virtual reality is increasingly being implemented in rehabilitative approaches for adult stroke patients.

OBJECTIVE

To analyze the existing scientific evidence regarding the application of immersive and non-immersive virtual reality in patients following cerebrovascular incidents and their efficacy in achieving dynamic and static balance. (2) Data sources: An electronic search of the databases Medline, Cochrane Library, PEDro, Scopus, and Scielo from January 2010 to December 2020 was carried out using the terms physiotherapy, physical therapy, virtual reality, immersive virtual reality, non-immersive virtual reality, stroke, balance, static balance, and dynamic balance.

SELECTION OF STUDIES

Randomized controlled trials in patients older than 18 developed with an adult population (>18 years old) with balance disorders as a consequence of suffering a stroke in the previous six months before therapeutic intervention, including exercises harnessing virtual reality in their interventions and evaluations of balance and published in English or Spanish, were included. A total of two hundred twenty-seven articles were found, ten of which were included for review and of these, nine were included in the subsequent meta-analysis. (3) Data extraction: Two authors selected the studies and extracted their characteristics (participants, interventions, and validation instruments) and results. The methodological quality of the studies was evaluated using the PEDro scale, and the risk of bias was determined using the Cochrane risk-of-bias tool.

DATA SYNTHESIS

Of the selected studies, three did not show significant improvements and seven showed significant improvements in the intervention groups in relation to the variables. (4) Conclusions: Non-immersive virtual reality combined with conventional rehabilitation could be considered as a therapeutic option.

Look Before You Leap: Interventions Supervised via Telehealth Involving Activities in Weight-Bearing or Standing Positions for People After Stroke-A Scoping Review

OBJECTIVE

The COVID-19 pandemic has seen a rapid shift to telehealth-delivered physical therapy services. Common impairments after stroke create unique challenges when providing rehabilitation via telehealth, particularly when it involves activities undertaken in weight-bearing or standing positions, including walking training. Our scoping review maps the evidence regarding safety, efficacy, and feasibility of remotely supervised telehealth interventions involving activities undertaken in weight-bearing or standing positions for people after stroke.

METHODS

Searches of relevant databases for primary research studies were conducted using keywords relating to exercise and telehealth. Studies of stroke survivors undertaking interventions involving activities in weight-bearing or standing positions, supervised in real-time via telehealth were included. Two reviewers independently appraised all studies. Data were charted by one reviewer, checked by another, and results synthesized narratively.

RESULTS

Seven studies (2 randomized trials, 1 mixed-methods, and 4 pre-post studies) were included, involving 179 participants. Some studies included stroke survivors with cognitive impairment, and 2 (29%) studies included only participants who walked independently. Adherence (reported in 3 studies) and satisfaction (reported in 4 studies) were good, and no serious adverse events (data from 4 studies) related to interventions were reported. Strategies to overcome technological barriers were used to optimize intervention safety and feasibility, along with physiological monitoring, caregiver assistance, and in-person exercise prescription. However, there is limited high-quality evidence of efficacy.

CONCLUSIONS

We identified strategies used in research to date that can support current practice. However, urgent research is needed to ensure that stroke survivors are receiving evidence-based, effective services.

IMPACT

The COVID-19 pandemic has necessitated a rapid shift to telerehabilitation services for people with stroke, but there is little evidence to guide best practice. Our review provides practical guidance and strategies to overcome barriers and optimize safety and adherence for telehealth interventions involving activities in weight-bearing or standing positions.

Effect of Exercise Interventions on Health-Related Quality of Life After Stroke and Transient Ischemic Attack: A Systematic Review and Meta-Analysis

Exercise interventions have been shown to help physical fitness, walking, and balance after stroke, but data are lacking on whether such interventions lead to improvements in health-related quality of life (HRQoL). In this systematic review and meta-analysis, 30 randomized controlled trials (n=1836 patients) were found from PubMed, OVID MEDLINE, Web of Science, CINAHL, SCOPUS, The Cochrane Library, and TRIP databases when searched from 1966 to February 2020 that examine the effects of exercise interventions on HRQoL after stroke or transient ischemic attack. Exercise interventions resulted in small to moderate beneficial effects on HRQoL at intervention end (standardized mean difference, -0.23 [95% CI, -0.40 to -0.07]) that appeared to diminish at longer-term follow-up (standardized mean difference, -0.11 [95% CI, -0.26 to 0.04]). Exercise was associated with moderate improvements in physical health (standardized mean difference, -0.33 [95% CI, -0.61 to -0.04]) and mental health (standardized mean difference, -0.29 [95% CI, -0.49 to -0.09]) domains of HRQoL while effects on social or cognitive composites showed little difference. Interventions that were initiated within 6 months, lasted at least 12 weeks in duration, involved at least 150 minutes per week, and included resistance training appeared most effective. Exercise can lead to moderate beneficial effects on HRQoL and should be considered an integral part of stroke rehabilitation.

Falls After Stroke: A Follow-up after Ten Years in Lund Stroke Register

OBJECTIVES

To evaluate incidence of self-reported falls and associated factors in a ten-year perspective after stroke.

METHODS

From a population-based cohort of first-ever stroke patients (n = 416) included in the Lund Stroke Register between March 1, 2001, and February 28, 2002, we performed a follow up of all 145 survivors ten years after stroke. We collected data on age, gender, main stroke type, living and housing situation, general health status (question 1 in the Short Form Health Survey (SF-36), dizziness, physical activity, Barthel Index, mobility aids, moving ability inside/outside, and health-related quality of life as defined by the EuroQol 3 dimension scale (EQ-5D-3L). Factors that may relate to falls were compared between those who had experienced falls after stroke or not.

RESULTS

Ten years after stroke, 49 patients (34 %) reported falls and 96 patients (66 %) reported no falls. Compared to patients with no falls, those who reported falls were older (median age 83.3 years vs 75.6 years; p < 0.001), more often lived alone, were more dependent in daily living, had less physical activity, poorer general health status, more often needed mobility aids, were more often unable to move alone outside, and had poorer health-related quality of life in all items in EQ-5D-3L except pain/discomfort.

CONCLUSIONS

Falls had occurred in approximately one third of the participants ten years after the stroke, and were strongly associated with several measures of frailty. Our results indicate that fall prevention should in particular focus on those at high risk of falls.

Associations between post-stroke motor and cognitive function: a cross-sectional study

BACKGROUND

Motor and cognitive impairments are frequently observed following stroke, but are often managed as distinct entities, and there is little evidence regarding how they are related. The aim of this study was to describe the prevalence of concurrent motor and cognitive impairments 3 months after stroke and to examine how motor performance was associated with memory, executive function and global cognition.

METHODS

The Norwegian Cognitive Impairment After Stroke (Nor-COAST) study is a prospective multicentre cohort study including patients hospitalized with acute stroke between May 2015 and March 2017. The National Institutes of Health Stroke Scale (NIHSS) was used to measure stroke severity at admission. Level of disability was assessed by the Modified Rankin Scale (mRS). Motor and cognitive functions were assessed 3 months post-stroke using the Montreal Cognitive Assessment (MoCA), Trail Making Test Part B (TMT-B), 10-Word List Recall (10WLR), Short Physical Performance Battery (SPPB), dual-task cost (DTC) and grip strength (Jamar®). Cut-offs were set according to current recommendations. Associations were examined using linear regression with cognitive tests as dependent variables and motor domains as covariates, adjusted for age, sex, education and stroke severity.

RESULTS

Of 567 participants included, 242 (43%) were women, mean (SD) age was 72.2 (11.7) years, 416 (75%) had an NIHSS score ≤ 4 and 475 (84%) had an mRS score of ≤2. Prevalence of concurrent motor and cognitive impairment ranged from 9.5% for DTC and 10WLR to 22.9% for grip strength and TMT-B. SPPB was associated with MoCA (regression coefficient B = 0.465, 95%CI [0.352, 0.578]), TMT-B (B = -9.494, 95%CI [- 11.726, - 7.925]) and 10WLR (B = 0.132, 95%CI [0.054, 0.211]). Grip strength was associated with MoCA (B = 0.075, 95%CI [0.039, 0.112]), TMT-B (B = -1.972, 95%CI [- 2.672, - 1.272]) and 10WLR (B = 0.041, 95%CI [0.016, 0.066]). Higher DTC was associated with more time needed to complete TMT-B (B = 0.475, 95%CI [0.075, 0.875]) but not with MoCA or 10WLR.

CONCLUSION

Three months after suffering mainly minor strokes, 30-40% of participants had motor or cognitive impairments, while 20% had concurrent impairments. Motor performance was associated with memory, executive function and global cognition. The identification of concurrent impairments could be relevant for preventing functional decline.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02650531 .

Effects on walking performance and lower body strength by short message service guided training after stroke or transient ischemic attack (The STROKEWALK Study): a randomized controlled trial

OBJECTIVE

To evaluate whetherdaily mobile-phone delivered messages with training instructions during three months increase physical activity and overall mobility in patients soon after stroke or transient ischemic attack.

DESIGN

Randomised controlled trial with intention-to-treat analyses.

SETTING

University hospital. Data collection from November 2016 until December2018.

SUBJECTS

Seventy-nine patients (mean (SD) age 63.9 (10.4) years, 29 were women) were allocated to either intervention (n = 40) or control group (n = 39). Participants had to be independent (modified Ranking Scale ⩽2) and able to perform the six-minute walking test at discharge from the hospital.

INTERVENTIONS

The intervention group received standard care and daily mobile phone instructional text messages to perform regular outdoor walking and functional leg exercises. The control group received standard care; that is, primary care follow-up.

MAIN MEASURES

Walking performance by six-minute walking test (m), lower body strength by five times chair-stand test (s), the short physical performance battery (0-12 points) and 10-metres walk test (m/s) were assessed at baseline and after three months.

RESULTS

The estimated median difference in the six-minute walking test was in favour of the intervention group by 30 metres (95% CI, 55 to 1; effect size 0.64; P = 0.037) and in the chair-stand test by 0.88 seconds (95% CI, 0.02 to 1.72; effect size 0.64; P = 0.034). There were no differences between groups on the short physical performance battery or in 10-metres walking time.

CONCLUSIONS

Three months of daily mobile phone text messages with guided training instructions improved composite mobility measures; that is, walking performanceand lower body strength.

CLINICAL TRIAL REGISTRY

The study is registered with ClinicalTrials.gov, number NCT02902367.

Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury

BACKGROUND

Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses.

METHODS

A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit.

RESULTS

Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality-based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality-based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight-supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance.

DISCUSSION

The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient's engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy.

LIMITATIONS

As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance.

SUMMARY

The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury.

DISCLAIMER

These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.

Preventive Approaches for Post-Stroke Depression: Where Do We Stand? A Systematic Review

PURPOSE

Post-stroke depression (PSD) occurs in one-third of stroke survivors, leading to a substantial decrease in quality of life as well as delayed functional and neurological recovery. Early detection of patients at risk and initiation of tailored preventive measures may reduce the medical and socioeconomic burden associated with PSD. We sought to review the current evidence on pharmacological and non-pharmacological prevention of PSD.

MATERIALS AND METHODS

We conducted a systematic review using PubMed/MEDLINE and bibliographies of identified papers following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including randomized controlled studies. Eligible studies were included when performed within 1 year after the index cerebrovascular event. Animal and basic research studies, studies lacking a control group, review papers, and case reports were excluded.

RESULTS

Out of 150 studies screened, 37 met our criteria. Among the strategies identified, administration of antidepressants displayed the most robust evidence for preventing PSD, whereas non-pharmacological interventions such as psychotherapy appear to be the most frequently used approaches to prevent depression after stroke. Research suggests that the efficacy of PSD prevention increases with the duration of preventive treatment. Seven out of 11 studies (63%) that used pharmacological and eight out of 16 (50%) that used non-pharmacological interventions reported a positive preventive effect on PSD.

CONCLUSION

Overall, the current literature on PSD prevention shows heterogeneity, substantiating a need for well-designed randomized controlled trials to test the safety and efficacy of pharmacological as well as non-pharmacological and composite prevention regimens to minimize the risk of PSD in stroke survivors. Integrative strategies combining personalized non-pharmacological interventions such as educational, mental, and physical health support, and pharmacological strategies such as SSRIs may be the most promising approach to prevent PSD.

Aerobic, resistance, and mind-body exercise are equivalent to mitigate symptoms of depression in older adults: A systematic review and network meta-analysis of randomised controlled trials

Background: Exercise has been identified as an allied health strategy that can support the management of depression in older adults, yet the relative effectiveness for different exercise modalities is unknown. To meet this gap in knowledge, we present a systematic review and network meta-analysis of randomised controlled trials (RCTs) to examine the head-to-head effectiveness of aerobic, resistance, and mind-body exercise to mitigate depressive symptoms in adults aged ≥ 65 years.

Methods: A PRISMA-NMA compliant review was undertaken on RCTs from inception to September 12 ^th, 2019. PubMed, Web of Science, CINAHL, Health Source: Nursing/Academic Edition, PsycARTICLES, PsycINFO, and SPORTDiscus were systematically searched for eligible RCTs enrolling adults with a mean age ≥ 65 years, comparing one or more exercise intervention arms, and which used valid measures of depressive symptomology. Comparative effectiveness was evaluated using network meta-analysis to combine direct and indirect evidence, controlling for inherent variation in trial control groups.

Results: The systematic review included 82 RCTs, with 69 meeting eligibility for the network meta-analysis ( n = 5,379 participants). Pooled analysis found each exercise type to be effective compared with controls (Hedges’ g = -0.27 to -0.51). Relative head-to-head comparisons were statistically comparable between exercise types: resistance versus aerobic (Hedges’ g = -0.06, PrI = -0.91, 0.79), mind-body versus aerobic (Hedges’ g = -0.12, PrI = -0.95, 0.72), mind-body versus resistance (Hedges’ g = -0.06, PrI = -0.90, 0.79). High levels of compliance were demonstrated for each exercise treatment.

Conclusions: Aerobic, resistance, and mind-body exercise demonstrate equivalence to mitigate symptoms of depression in older adults aged ≥ 65 years, with comparably encouraging levels of compliance to exercise treatment. These findings coalesce with previous findings in clinically depressed older adults to encourage personal preference when prescribing exercise for depressive symptoms in older adults.

Registration: PROSPERO CRD42018115866 (23/11/2018).

Aerobic, resistance, and mind-body exercise are equivalent to mitigate symptoms of depression in older adults: A systematic review and network meta-analysis of randomised controlled trials

Background: Exercise has been identified as an allied health strategy that can support the management of depression in older adults, yet the relative effectiveness for different exercise modalities is unknown. To meet this gap in knowledge, we present a systematic review and network meta-analysis of randomised controlled trials (RCTs) to examine the head-to-head effectiveness of aerobic, resistance, and mind-body exercise to mitigate depressive symptoms in adults aged ≥ 65 years. Methods: A PRISMA-NMA compliant review was undertaken on RCTs from inception to September 12 th, 2019. PubMed, Web of Science, CINAHL, Health Source: Nursing/Academic Edition, PsycARTICLES, PsycINFO, and SPORTDiscus were systematically searched for eligible RCTs enrolling adults with a mean age ≥ 65 years, comparing one or more exercise intervention arms, and which used valid measures of depressive symptomology. Comparative effectiveness was evaluated using network meta-analysis to combine direct and indirect evidence, controlling for inherent variation in trial control groups. Results: The systematic review included 82 RCTs, with 69 meeting eligibility for the network meta-analysis ( n = 5,379 participants). Pooled analysis found each exercise type to be effective compared with controls (Hedges' g = -0.27 to -0.51). Relative head-to-head comparisons were statistically comparable between exercise types: resistance versus aerobic (Hedges' g = -0.06, PrI = -0.91, 0.79), mind-body versus aerobic (Hedges' g = -0.12, PrI = -0.95, 0.72), mind-body versus resistance (Hedges' g = -0.06, PrI = -0.90, 0.79). High levels of compliance were demonstrated for each exercise treatment. Conclusions: Aerobic, resistance, and mind-body exercise demonstrate equivalence to mitigate symptoms of depression in older adults aged ≥ 65 years, with comparably encouraging levels of compliance to exercise treatment. These findings coalesce with previous findings in clinically depressed older adults to encourage personal preference when prescribing exercise for depressive symptoms in older adults. Registration: PROSPERO CRD42018115866 (23/11/2018).

Efficacy of task-specific circuit training on physical activity levels and mobility of stroke patients: A randomized controlled trial

BACKGROUND

Impaired mobility is related to low physical activity (PA) levels observed after stroke. Therapeutic approaches, such as task-specific circuit training (TSCT), used to improve mobility in individuals with stroke, could also improve PA levels.

OBJECTIVE

To investigate the efficacy of TSCT, focused on both upper (UL) and lower (LL) limbs, in improving PA levels and mobility (primary outcomes), as well as muscle strength, exercise capacity, and quality of life (secondary outcomes) in subjects with stroke.

METHODS

A randomized controlled trial with 36 subjects with chronic stroke was conducted. Experimental group: TSCT, involving both UL and LL.

CONTROL GROUP

global stretching, memory exercises, and education sessions. Both groups received 60 minute sessions/week over 12 weeks. Outcomes were measured at baseline, post-intervention and 16 week follow-up.

RESULTS

No changes were found for primary and secondary outcomes (0.11≤p≤0.99), except for quality of life, which improved in the experimental group post-intervention and 16 week follow-up (p = 0.02).

CONCLUSION

TSCT focused on both UL and LL was not effective on PA levels and mobility of individuals with chronic stroke, however, improvements in quality of life were observed. Since this is the first study to investigate this combined training aimed at improving PA levels, future studies are necessary to better understand the impact of this type of intervention.

Generalizability of Results from Randomized Controlled Trials in Post-Stroke Physiotherapy

Purpose: The randomized controlled trial (RCT) is considered a reliable experimental design, able to detect the effect of an intervention. However, a criticism frequently levelled at RCTs by clinicians is their lack of generalizability. This study aimed to evaluate the generalizability of findings from RCTs of physiotherapy interventions for individuals with stroke. Method: A sample of RCTs of physiotherapy interventions after stroke indexed in the PEDro database was selected, and the reported inclusion and exclusion criteria were analyzed. Results: We reviewed 100 articles, which included 7,366 participants (41.6% women, with a mean weighted age of 65.5 years). The most frequent criteria for exclusion were comorbidity (83%), cognitive impairments (69%), communication skills (55%), recurrent stroke (53%), low functional level (47%) and being elderly (25%). Conclusions: A variety of cohorts of individuals who have had a stroke are excluded from RCTs published in the field of physiotherapy. Because they represent a substantial proportion of the real-world population with stroke, and consequently treated in clinical practice, more vulnerable cohorts of participants should be included in RCTs.

Innovative Long-Dose Neurorehabilitation for Balance and Mobility in Chronic Stroke: A Preliminary Case Series

(1) Objective: The objective was two-fold: (a) test a protocol of combined interventions; (b) administer this combined protocol within the framework of a six-month, intensive, long-duration program. The array of interventions was designed to target the treatment-resistant impairments underlying persistent mobility dysfunction: weakness, balance deficit, limb movement dyscoordination, and gait dyscoordination. (2) Methods: A convenience sample of eight chronic stroke survivors (>4 months post stroke) was enrolled. Treatment was 5 days/week, 1-2.5 h/day for 6 months, as follows: strengthening exercise, balance training, limb/gait coordination training, and aerobic exercise. Outcome measures: Berg Balance Scale (BBS), Fugl-Meyer Lower Limb Coordination (FM), gait speed, 6 Minute Walk Test (6MWT), Timed up and Go (TUG), Functional Independence Measure (FIM), Craig Handicap Assessment Rating Tool (CHART), and personal milestones. Pre-/post-treatment comparisons were conducted using the Permutation Test, suitable for ordinal measures and small sample size. (3) Results: For the group, there was a statistically (p ≤ 0.04) significant improvement in balance, limb movement coordination (FM), gait speed, functional mobility (TUG), and functional activities (FIM). There were measurable differences (minimum detectible change: MDC) in BBS, FM, gait speed, 6MWT, and TUG. There were clinically significant milestones achieved for selected subjects according to clinical benchmarks for the BBS, 6MWT, gait speed, and TUG, as well as achievement of personal milestones of life role participation. Effect sizes (Cohen's D) ranged from 0.5 to 1.0 (with the exception of the (6MWT)). After six months of treatment, the above array of gains were beyond that reported by other published studies of chronic stroke survivor interventions. Personal milestones included: walking to mailbox, gardening/yardwork, walking a distance to neighbors, return to driving, membership at a fitness center, vacation trip to the beach, swimming at local pool, returning to work, housework, cooking meals. (4) Conclusions: Stroke survivors with mobility dysfunction were able to participate in the long-duration, intensive program, with the intervention array targeted to address impairments underlying mobility dysfunction. There were either clinically or statistically significant improvements in an array of measures of impairment, functional mobility, and personal milestone achievements.

Development of a Care Bundle for Stroke Survivors with Psychological Symptoms: Evidence Summary and Delphi Study

Background

Psychological symptoms such as depression and anxiety are quite common among stroke survivors and have great negative impacts on patients.

Objective

To develop a care bundle through reviewing and integrating care strategies for psychological symptoms after stroke and then improve the bundle by Delphi study.

Methods

A structured search of the literature was performed to identify studies evaluating interventions for stroke patients with psychological symptoms such as depression and anxiety. Two trained researchers screened papers through the titles, abstracts, and full-texts independently. All studies complying with the eligibility criteria were appraised using quality assessment tools. Related interventions with evaluated evidence levels formed the preliminary bundle. Afterward, the Delphi study was carried out to improve the bundle, and the experts were contacted by e-mail. Ten clinical experts specialized in stroke and psychological rehabilitation were recruited. The reliability of experts was represented by the effective response rate and authority coefficient (Cr). The consensus was deemed to be reached when the mean score for item importance is all equal or above 3.50 and the coefficient of variation (CV) is all equal or below 0.20. The Kendall coefficient W test was adopted to evaluate the consensus on agreement among the experts as well. Data analysis was performed using SPSS V.22.0.

Results

Through a systematic evidence summary and two-round Delphi study, the items that were given high scores and got consensus by experts were chosen for the bundle. The iDAME bundle consisted of five interventions eventually: maintaining Interaction, tailored Diet, Acupressure, mindfulness Meditation, and physical Exercise.

Conclusion

The development of an evidence-based and consensus-based iDAME bundle which integrated western and traditional Chinese medicine intervention was described. Evidence summary made the bundle become scientific, while the Delphi study made it more maneuverable. Based on these results, the bundle would be potentially implemented in stroke patients for their psychological symptoms.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical activity and physical fitness are low after stroke. Interventions to increase physical fitness could reduce mortality and reduce disability through increased function.

OBJECTIVES

The primary objectives of this updated review were to determine whether fitness training after stroke reduces death, death or dependence, and disability. The secondary objectives were to determine the effects of training on adverse events, risk factors, physical fitness, mobility, physical function, health status and quality of life, mood, and cognitive function.

SEARCH METHODS

In July 2018 we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, and four additional databases. We also searched ongoing trials registers and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses and assessed the quality of the evidence using the GRADE approach. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 75 studies, involving 3017 mostly ambulatory participants, which comprised cardiorespiratory (32 studies, 1631 participants), resistance (20 studies, 779 participants), and mixed training interventions (23 studies, 1207 participants). Death was not influenced by any intervention; risk differences were all 0.00 (low-certainty evidence). There were few deaths overall (19/3017 at end of intervention and 19/1469 at end of follow-up). None of the studies assessed death or dependence as a composite outcome. Disability scores were improved at end of intervention by cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% CI 0.19 to 0.84; 8 studies, 462 participants; P = 0.002; moderate-certainty evidence) and mixed training (SMD 0.23, 95% CI 0.03 to 0.42; 9 studies, 604 participants; P = 0.02; low-certainty evidence). There were too few data to assess the effects of resistance training on disability. Secondary outcomes showed multiple benefits for physical fitness (VO2 peak and strength), mobility (walking speed) and physical function (balance). These physical effects tended to be intervention-specific with the evidence mostly low or moderate certainty. Risk factor data were limited or showed no effects apart from cardiorespiratory fitness (VO2 peak), which increased after cardiorespiratory training (mean difference (MD) 3.40 mL/kg/min, 95% CI 2.98 to 3.83; 9 studies, 438 participants; moderate-certainty evidence). There was no evidence of any serious adverse events. Lack of data prevents conclusions about effects of training on mood, quality of life, and cognition. Lack of data also meant benefits at follow-up (i.e. after training had stopped) were unclear but some mobility benefits did persist. Risk of bias varied across studies but imbalanced amounts of exposure in control and intervention groups was a common issue affecting many comparisons.

AUTHORS' CONCLUSIONS

Few deaths overall suggest exercise is a safe intervention but means we cannot determine whether exercise reduces mortality or the chance of death or dependency. Cardiorespiratory training and, to a lesser extent mixed training, reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve fitness, balance and the speed and capacity of walking. The magnitude of VO2 peak increase after cardiorespiratory training has been suggested to reduce risk of stroke hospitalisation by ˜7%. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription, the range of benefits and any long-term benefits.

Randomized controlled trial of SystemCHANGE™ weight management intervention in neurological conditions

OBJECTIVE

This randomized controlled pilot study examined the feasibility and efficacy of a SystemCHANGE™ (SC) weight management intervention in adults with either multiple sclerosis or stroke.

METHODS

Participants (n = 61) were randomized into two interventions: SC, which taught skills to modify personal environments, or active-control (AC), which taught health behavior guidelines. Sessions were held weekly for 12 weeks. Feasibility measures included recruitment and attrition rates. The primary outcome of body weight and secondary outcomes of emotional well-being and healthy behaviors were measured before and after the interventions.

RESULTS

Average recruitment rate was 3.6 participants per month. Attrition rate was 14.8%. On average, 9.1 sessions were completed for SC and 10.7 for AC. Differences in weight loss were non-significant between interventions (P = 0.182), but significantly declined across both interventions (P = 0.011). Physical activity (P = 0.002), depression (P < 0.001), anxiety (P = 0.023), and self-efficacy (P = 0.022) all significantly improved for SC compared to AC.

CONCLUSIONS

SC was feasible to implement and efficacious in improving secondary outcomes of emotional well-being and healthy behaviors, but was not efficacious in improving the primary outcome of weight loss. More research is needed to optimize SC.

PRACTICE IMPLICATIONS

SC might be an alternative approach to cognitive-behavioral therapy for promoting emotional well-being and healthy behaviors.

Exercise as a prescription for patients with various diseases

A growing understanding of the benefits of exercise over the past few decades has prompted researchers to take an interest in the possibilities of exercise therapy. Because each sport has its own set of characteristics and physiological complications that tend to occur during exercise training, the effects and underlying mechanisms of exercise remain unclear. Thus, the first step in probing the effects of exercise on different diseases is the selection of an optimal exercise protocol. This review summarizes the latest exercise prescription treatments for 26 different diseases: musculoskeletal system diseases (low back pain, tendon injury, osteoporosis, osteoarthritis, and hip fracture), metabolic system diseases (obesity, type 2 diabetes, type 1 diabetes, and nonalcoholic fatty liver disease), cardio-cerebral vascular system diseases (coronary artery disease, stroke, and chronic heart failure), nervous system diseases (Parkinson's disease, Huntington's disease, Alzheimer's disease, depression, and anxiety disorders), respiratory system diseases (chronic obstructive pulmonary disease, interstitial lung disease, and after lung transplantation), urinary system diseases (chronic kidney disease and after kidney transplantation), and cancers (breast cancer, colon cancer, prostate cancer, and lung cancer). Each exercise prescription is displayed in a corresponding table. The recommended type, intensity, and frequency of exercise prescriptions are summarized, and the effects of exercise therapy on the prevention and rehabilitation of different diseases are discussed.

A randomized study of botulinum toxin versus botulinum toxin plus physical therapy for treatment of cervical dystonia

BACKGROUND

Physical therapy (PT) for cervical dystonia is not well studied, and the underlying physiological effects are not known.

METHODS

We enrolled 26 subjects comprising of 16 cervical dystonia and 10 healthy controls for normative physiological data. We randomized cervical dystonia patients who reported suboptimal benefits on botulinum toxin (BoNT) injections to BoNT alone (BoNT arm) or BoNT plus PT (PT-BoNT arm). PT-BoNT arm received manual PT on the injection day followed by six weeks of home-exercise program. Home-exercise program comprised of stretching, range-of-motion and isometric exercises. The primary outcome was change from baseline in Toronto Western spasmodic torticollis rating scale (TWSTRS) that was recorded six weeks after exercise program. TWSTRS was video evaluated by blinded raters. We probed sensorimotor plasticity with transcranial magnetic stimulation (TMS) using a paired associative stimulation (PAS) paradigm.

RESULTS

TWSTRS score improved (severity 31%, p = 0.002; pain 28%, p = 0.01) and PAS plasticity decreased (p = 0.01) in PT-BoNT arm compared to BoNT arm. PAS values for PT-BoNT arm were found to approach values of healthy control values. Change in PAS measure correlated significantly with TWSTRS change (severity, r = 0.56, p = 0.04; pain, r = 0.61, p = 0.03. TWSTRS disability score only approached significance (p = 0.14) when comparing the two treatment arms.

CONCLUSION

PT is a potential adjunct in patients with cervical dystonia who report suboptimal benefits with BoNT therapy. PT related benefits in cervical dystonia are likely mediated through modulation of sensorimotor plasticity.

Efficacy of interventions aimed at improving physical activity in individuals with stroke: a systematic review

Purpose: To identify interventions employed to increase post-stroke physical activity, evaluate their efficacy, and identify the gaps in literature.Materials and methods: Randomized controlled trials published until March 2018 were searched in MEDLINE, PEDro, EMBASE, LILACS, and SCIELO databases. The quality of each study and overall quality of evidence were assessed using the PEDro and the GRADE scales.Results: Eighteen studies were included (good PEDro and very low GRADE-scores). In seven, the experimental groups showed significant increases in physical activity (aerobics, resistance, and home-based training; counseling, aerobics, resistance, and home-based training; electrical stimulation during walking; functional-task training; robot-assisted arm therapy; accelerometer-based feedback, and physical activity encouragement). In seven, there were no significant between-group differences (physical activity plan; stretching, use of toe-spreaders, standard treatment; counseling; circuit video-game; functional-task; counseling and cognitive training). The combined experimental and control groups showed significant declines in physical activity in one study (aerobic training or stretching) and increases in three others (aerobic, resistance or sham resistance training; stroke-with advice or only stroke-counseling; aerobic training, educational sessions, standard treatment, and coaching, or mobilization and standard treatment). A meta-analysis could not be performed, due to heterogeneity.Conclusions: Some interventions improved physical activity after stroke. However, the interpretability is limited.Implications for rehabilitationIndividuals with stroke show low physical activity, which may compromise function and health.The use of interventions aimed at improving and maintaining physical activity of individuals with stroke are recommended.Some interventions, such as aerobic, resistance, and combined home-based training, electrical stimulation during walking, functional task training, and arm robot-assisted therapy, could improve the physical activity after stroke.

A wearable resistive robot facilitates locomotor adaptations during gait

BACKGROUND

Robotic-resisted treadmill walking is a form of task-specific training that has been used to improve gait function in individuals with neurological injury, such as stroke, spinal cord injury, or cerebral palsy. Traditionally, these devices use active elements (e.g., motors or actuators) to provide resistance during walking, making them bulky, expensive, and less suitable for overground or in-home rehabilitation. We recently developed a low-cost, wearable robotic brace that generates resistive torques across the knee joint using a simple magnetic brake. However, the possible effects of training with this device on gait function in a clinical population are currently unknown.

OBJECTIVE

The purpose of this study was to test the acute effects of resisted walking with this device on kinematics, muscle activation patterns, and gait velocity in chronic stroke survivors.

METHODS

Six stroke survivors wore the resistive brace and walked on a treadmill for 20 minutes (4×5 minutes) at their self-selected walking speed while simultaneously performing a foot trajectory-tracking task to minimize stiff-knee gait. Electromyography, sagittal plane gait kinematics, and overground gait velocity were collected to evaluate the acute effects of the device on gait function.

RESULTS

Robotic-resisted treadmill training resulted in a significant increase in quadriceps and hamstring EMG activity during walking. Significant aftereffects (i.e., improved joint excursions) were also observed on the hip and knee kinematics, which persisted for several steps after training. More importantly, training resulted in significant improvements in overground gait velocity. These results were consistent in all the subjects tested.

CONCLUSION

This study provides preliminary evidence indicating that robotic-resisted treadmill walking using our knee brace can result in meaningful biomechanical aftereffects that translate to overground walking.

Protocol and pilot study of a short message service-guided training after acute stroke/transient ischemic attack to increase walking capacity and physical activity

Physical activity in community-living individuals after a stroke is usually scarce. This protocol describes a study that will evaluate a method to increase physical activity by performing a 3-month outdoor walking and muscle strengthening program and will examine the 3-month and 1-year effects of this program on individuals with acute stroke (AS) or transient ischemic attack (TIA). In a prospective randomized controlled trial in Uppsala, Sweden, 80 individuals with AS or TIA who maintained cognitive and motor function will be randomized into groups for continuous training for three months or for regular standard care. The training will be supervised by daily cellphone-delivered messages (short message services; SMS), and the intensity, duration and workload will be gradually increased. The primary outcome is a change in walking capacity according to the 6-Minute Walk Test and chair-rising at three months. Secondary outcomes include mobility, gait speed, handgrip strength, body composition (fat mass and muscle mass), biochemical risk-markers, health-related quality of life, and cardiovascular events. Adherence to the training program will be documented with a self-reported diary and step counts over two weeks. The major study started in November 2016, and results are expected in 2019. In a pilot study of 15 subjects post-stroke (mean-age 65 years), we observed improved walking capacity (increasing from 23 to 255 m) and chair-rising (decreasing 2.42 s) from baseline to three months. SMS-guided outdoor training will be tested as a potential therapeutic strategy to increase physical activity and thereby improve walking capacity and physical function following a stroke.

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In contrast to many post-stroke exercise studies this study focus on the close post-stroke period.

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The use of SMS and cellphones to communicate might improve the motivation to exercise.

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Outdoor walking/strength training in the close post-stroke period might prove to be a therapeutic strategy.