Physical fitness training for stroke patients

Stroke survivor and caregiver perspectives in the development of a community water-based therapeutic exercise program

BACKGROUND

Water-based therapeutic exercise (WBTE) is an effective approach for stroke survivors to regain strength, mobility, and quality of life. However, existing trials have not included stroke survivors' perspectives in intervention development, which are critical to ensure a WBTE program meets the needs of stroke survivors and provides supports to enable engagement in ongoing exercise.

METHODS

Qualitative semi-structured interviews were completed with stroke survivors and caregivers with the aim to have them (1) provide feedback on elements of the intervention resulting from a preceding scoping review and (2) identify barriers, facilitators and other considerations that may impact implementation. Literature on the development of complex health interventions and implementation science informed interview topics. Interviews were analyzed using generic coding and thematic analysis for open-ended and closed-ended questions, respectively.

RESULTS

Stroke survivor and caregivers largely confirmed findings from the scoping review regarding intervention characteristics. Four main considerations for implementation were identified in interview analysis: (1) safety, (2) knowledge and beliefs, (3) environment, and (4) individual characteristics.

CONCLUSION

It is essential to consider stroke survivor and caregiver perspectives when developing interventions to promote ongoing exercise following formal rehabilitation. The unique needs of each stroke survivor should be evaluated to optimize participation in WBTE.

Supervised exercise after minor stroke: an evaluation from the perspective of patients and healthcare professionals

OBJECTIVE

Maintaining long-term physical activity after a stroke is challenging. "The Stroke School", a standardized physical exercise programme, was developed and patients' and healthcare professionals' experiences of participating were explored.

DESIGN

Qualitative study.

METHODS

Eight patients with minor stroke or transient ischaemic attack (TIA) completed a feasibility study on The Stroke School intervention in conjunction with their supervising municipal physiotherapists (n = 5). All informants were invited for semi-structured focus-group interviews, during which they were asked to reflect on their experience attending The Stroke School. Audio recordings from 3 focus-group interviews lasting 90 min each were transcribed to text verbatim and analysed with qualitative content analysis.

RESULTS

Thirteen informants attended 3 focus-group interviews. Five categories were identified (i-iii representing the patients' perspective and iv-v the physiotherapists' perspectives): (i) window of opportunity, (ii) benefits of participating in the study, (iii) strengths and pitfalls of transitioning from the hospital to the municipalities, (iv) effective communication across sectors, and (v) empowering patients to continue exercising independently.

CONCLUSION

The Stroke School intervention was feasible, provided patient safety throughout the study, and resulted in effective communication and collaboration across sectors. However, identifying factors that facilitate life-long exercise behaviour changes is still warranted.

Current exercise-based rehabilitation impacts on poststroke exercise capacity, blood pressure, and lipid control: a meta-analysis

Objectives

This systematic review aimed to evaluate the impact of post-stroke exercise-based rehabilitation programs on blood pressure, lipid profile, and exercise capacity.

Methods

Through a systemic search of literature from inception to 2024 using five databases, we analyzed data on the mean difference (MD) using a meta-analysis method to estimate effectiveness.

Results

Thirty-seven randomized control trials were included encompassing various exercises such as aerobic, resistance, stretching, exergaming, robot-assisted training, and community-based training. Significant improvement was illustrated at discharge in systolic [MD 2.76 mmHg; 95% confidence interval (CI) -1.58 to 3.92, P < 0.05] and diastolic (MD 1.28 mmHg; 95% CI 0.54-2.12, P < 0.05) blood pressure and peak oxygen volume (MD -0.29 ml/kg/min; 95% CI -0.53 to 0.05, P < 0.05). We also observed significant improvement at discharge in high-density lipoprotein only after resistance exercise from two articles and low-density lipoprotein only in the intervention groups compared to the control groups from ten articles.

Conclusion

Overall, current exercise-based rehabilitation programs significantly improve blood pressure and exercise capacity in patients with stroke at discharge. However, lipoprotein changes remained inconclusive. Although ameliorative changes were noted in most variables, more research is needed to determine optimum exercise intensity, type combination, and health education to reduce post-stroke complications and mortality.

Systematic Review Registration

https://doi.org/10.17605/OSF.IO/X89FW.

Stroke Rehabilitation: Synopsis of the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

In July 2024, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DOD) released a joint update of their 2019 clinical practice guideline (CPG) for the management of stroke rehabilitation. This synopsis is a condensed version of the 2024 CPG, highlighting the key aspects of the guideline development process and describing the major recommendations.

METHODS

The VA/DOD Evidence-Based Practice Work Group convened a joint VA/DOD guideline development work group (WG) that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy CPGs. The guideline WG conducted a patient focus group, developed key questions, and systematically searched and evaluated the literature (English-language publications from 1 July 2018 to 2 May 2023). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to evaluate the evidence. The WG developed 47 recommendations along with algorithms for stroke rehabilitation in the inpatient and outpatient settings. Stakeholders outside the WG reviewed the CPG before approval by the VA/DOD Evidence-Based Practice Work Group.

RECOMMENDATIONS

This synopsis summarizes where evidence is strongest to support guidelines in crucial areas relevant to primary care physicians: transition to community (case management, psychosocial or behavioral interventions); motor therapy (task-specific practice, mirror therapy, rhythmic auditory stimulation, electrical stimulation, botulinum toxin for spasticity); dysphagia, aphasia, and cognition (chin tuck against resistance, respiratory muscle strength training); and mental health (selective serotonin reuptake inhibitor use, psychotherapy, mindfulness-based therapies for treatment but not prevention of depression).

Characterizing objective and self-report habitual physical activity and sedentary time in outpatients with an acquired brain injury

Outpatients with an acquired brain injury (ABI) experience physical, mental, and social deficits. ABI can be classified into two subgroups based on mechanism of injury: mild traumatic brain injury (mTBI; e.g., concussion) and other ABI (e.g., stroke, brain aneurysm, encephalitis). Our understanding of habitual activity levels within ABI populations is limited because they are often collected using self-report measures. The purpose of this study was to, 1) describe the habitual activity levels of outpatients with ABI using objective and self-report monitoring, and 2) compare the activity levels of outpatients with mTBI vs. other ABI. Sixteen outpatients with other ABI (mean ​± ​standard deviation: [58 ​± ​13] years, 9 females) and 12 outpatients with mTBI ([48 ​± ​11] years, 9 females) wore a thigh-worn activPAL 24 ​h/day (h/day) for 7-days. Outpatients with ABI averaged (6.0 ​± ​2.3) h/day of upright time, (10.6 ​± ​2.2) h/day of sedentary time, (5.6 ​± ​2.7) h/day in prolonged sedentary bouts > 1 ​h, (5 960 ​± ​3 037) steps/day, and (11 ​± ​13) minutes/day (min/day) of moderate-vigorous physical activity (MVPA). There were no differences between activPAL-derived upright, sedentary, prolonged sedentary time, and physical activity between the mTBI and other ABI groups (all, p ​> ​0.31). Outpatients with ABI overestimated their MVPA levels (+138 ​min/week) and underestimated sedentary time (-4.3 ​h/day) compared to self-report (all, p ​< ​0.001). Despite self-reporting high activity levels, outpatients with ABI objectively exhibit highly inactive and sedentary lifestyles. The habitual movement behaviours of our sample did not differ by mechanism of injury (i.e., mTBI versus other ABI). Targeting reductions in objectively measured sedentary time are needed to progressively improve the habitual movement behaviours of outpatients with ABI.

Effects of Assisted Walking Exercise in Chronic Dependent Ambulatory Stroke Survivors: A Mini-Review

Background

Assisted walking exercise programs are widely recommended in rehabilitation guidelines for stroke survivors. However, most evidence supporting these programs primarily focuses on ambulatory stroke survivors or those dependent ambulatory in acute and subacute stages. There is a notable gap in the application of walking exercise programs for chronic dependent ambulatory stroke survivors despite potential benefits in reducing sedentary behavior and improving rehabilitation outcomes. Thus, this literature review aims to summarize the existing evidence on the feasibility and efficacy of assisted walking exercise programs for chronic stroke survivors who are dependent ambulators.

Methods

Six major databases were searched for clinical trials related to assisted walking exercise and chronic dependent ambulatory stroke.

Results

Seven studies (evidence with low- to moderate-quality) involving 91 chronic dependent ambulatory stroke subjects are included in this review.

Conclusions

These studies indicated that assisted walking exercise is feasible to perform by chronic dependent ambulatory stroke survivors and can induce continued motor recovery and functional improvement. However, the mixed and limited evidence from existing research underscores the need for future high-quality randomized controlled trials with standardized designs and outcome measures to establish evidence-based walking programs for this population.

Evaluating the Educational Experience of Physiotherapy Students Using the Fitness and Mobility Exercise (FAME) Programme to Learn about Neurological Conditions: An Exploratory Study

Purpose

Group exercise has the potential to be a cost-effective way to improve functional outcomes for those living with neurological injury. Leading group exercise is a foundational competency for entry-to-practice for physiotherapy students. The overall objective of this study was to examine the student experience of using the Fitness and Mobility Exercise (FAME) programme to learn about neurological conditions in a group setting.

Methods

Sixteen physiotherapy students filled out a single point in time survey at the end of their placement during which they had the opportunity to use FAME with their clients twice a week. The survey had Likert and open-ended questions and demographic information. Likert responses were calculated as means. Open-ended questions were analyzed using thematic analysis.

Results

The Likert questions were answered with almost entirely positive results. The main themes from the open-ended questions were how to personalize the class, characteristics of individual clients shape the class experience and factors that make the class successful.

Conclusions

Overall, the physiotherapy students found using FAME to be a positive experience. From the student perspective, using FAME during placement was an effective way to learn about neurological conditions as well as to develop skills to manage a group exercise class.

Integrating Cardiac Rehabilitation in Stroke Recovery

Stroke remains a top contributor to long-term disability in the United States and substantially limits a person's physical activity. Decreased cardiovascular capacity is a major contributing factor to activity limitations and is a significant health concern. Addressing the cardiovascular capacity of stroke survivors as part of poststroke management results in significant improvements in their endurance, functional recovery, and medical outcomes such as all-cause rehospitalization and mortality. Incorporation of a structured approach similar to the cardiac rehabilitation program, including aerobic exercise and risk factor education, can lead to improved cardiovascular function, health benefits, and quality of life in stroke survivors.

Updated Perspectives on Lifestyle Interventions as Secondary Stroke Prevention Measures: A Narrative Review

Despite being highly preventable, stroke is the second-most common cause of death and disability in the world. Secondary prevention is critical as the stroke recurrence risk is 6- to 15-fold higher than the risk of stroke in the general population. Stroke recurrence is associated with higher mortality rates and increased disability levels. Lifestyle modifications should address not single but multiple cardiovascular risk factors to effectively reduce the risk of stroke. Lifestyle modifications on a personal level should include adequate physical activity, a healthy diet, the cessation of smoking and alcohol consumption, and stress reduction. Physical activities should be performed in a healthy environment without air pollution. According to recent studies, up to 90% of strokes might be prevented by addressing and treating ten modifiable stroke risk factors, half of which are related to lifestyle modifications. These lifestyle modifications, which are behavioral interventions, could impact other modifiable risk factors such as arterial hypertension, hyperlipidemia, obesity, diabetes, and atrial fibrillation. The most common obstacles to effective secondary stroke prevention are motor impairment, post-stroke cognitive impairment, post-stroke depression, and stroke subtype. Long-term lifestyle modifications are difficult to sustain and require comprehensive, individualized interventions. This review underlines the benefits of adhering to lifestyle modifications as the most effective secondary stroke prevention measure.

The Life After Stroke In Northern Sweden Study (LASINS): Methodology, cohort demographics and initial results

BACKGROUND

To advance rehabilitation we need a comprehensive understanding of functioning and disability of people after stroke.

OBJECTIVE

To present an overview of the methodology of the Life After Stroke In Northern Sweden Study, compare participants and non-participants regarding gender and age, and describe baseline sociodemographics, stroke characteristics and the participants' self-rated degree of recovery.

METHODS

Data were collected through a study specific questionnaire, from the participants' medical records and with internationally established self-assessment tools focusing on sleep disturbances, depressive symptoms, fatigue, physical activity, and remaining physical and cognitive impairments, activity limitations, participation restrictions and life satisfaction.

RESULTS

Of 301 potential participants, 160 comprise the final sample (response rate 53%; 86 men and 74 women, mean age 73 years±11, mean time since stroke onset 35 months±11; 18- 61). Most participants had an ischemic stroke (87%), were retired (84%), cohabitant (63%) and walked independently (71%). The mean self-rated degree of recovery was 75 (SD±24; 0- 100).

CONCLUSIONS

These baseline data together with forthcoming studies will describe stroke-related impairments, activity limitations, participation restrictions and life satisfaction more than one year after stroke, and deepen our understanding of factors of importance for a healthy and successful life after stroke.

Impact of a history of cardiovascular disease and physical activity habits on the incidence of functional disability

We examined the impact of a history of coronary artery disease (CAD) or cerebrovascular disease (CVD) and physical activity habits on functional disability among community-dwelling Japanese adults. This population-based retrospective cohort study included 10,661 people aged 39-98 years in Japan (5054, men). Median follow-up was 3.7 years. During the study period, 209 functional disabilities occurred in the overall study population. In multivariable analysis, a history of CVD (hazard ratio [HR] 1.57 [95% CI: 1.00-2.45]) and no physical activity habit (HR 1.74 [1.27-2.39]) presented increased risks for functional disability. HRs for functional disability among patients with a CVD history with and without a physical activity habit were 1.68 (0.75-3.74) and 2.65 (1.49-4.71), respectively, compared with individuals without a history of CVD with a physical activity habit. Similar results were observed for CAD. We found no significant difference in the incidence of functional disability between the group with a history of CAD or CVD and physical activity habits and the group with no history of CAD or CVD and without physical activity habits. Physical activity habits had a favorable influence on avoiding functional disability regardless of a history of CAD or CVD. Future prospective studies are needed to clarify these associations.

EXERTION: a pilot trial on the effect of aerobic, smartwatch-controlled exercise on stroke recovery: effects on motor function, structural repair, cognition, mental well-being, and the immune system

INTRODUCTION

Motor impairments are the objectively most striking sequelae after stroke, but non-motor consequences represent a high burden for stroke survivors as well. Depression is reported in one third of patients, the fatigue prevalence ranges from 23 to 75% due to heterogenous definitions and assessments. Cognitive impairment is found in one third of stroke patients 3-12 months after stroke and the risk for dementia is doubled by the event. Aerobic exercise has been shown to reduce depressive symptoms, counteract fatigue, and improve cognitive functions in non-stroke patients. Furthermore, exercise is known to strengthen the immune system. It is unknown, though, if aerobic exercise can counteract poststroke depression, fatigue, poststroke dementia and poststroke immunosuppression. Therefore, we aim to analyse the effect of aerobic exercise on functional recovery, cognition, emotional well-being, and the immune system. Reorganization of topological networks of the brain shall be visualized by diffusion MRI fibre tracking.

METHODS

Adults with mild to moderate stroke impairment (initial NIHSS or NIHSS determined at the moment of maximal deterioration 1-18) are recruited within two weeks of stroke onset. Study participants must be able to walk independently without risk of falling. All patients are equipped with wearable devices (smartwatches) measuring the heart rate and daily step count. The optimal heart rate zone is determined by lactate ergometry at baseline. Patients are randomized to the control or the intervention group, the latter performing a heart rate-controlled walking training on own initiative 5 times a week for 45 min. All patients receive medical care and stroke rehabilitation to the usual standard of care. The following assessments are conducted at baseline and after 90 days: Fugl Meyer-assessment for the upper and lower extremity, 6 min-walk test, neuropsychological assessment (cognition: MoCA, SDMT; fatigue and depression: FSMC, HADS-D, participation: WHODAS 2.0 12-items), blood testing (i.e. immune profiling to obtain insights into phenotype and functional features of distinct immune-cell subsets) and cranial magnetic resonance imaging (MRI) with grid-sampled diffusion weighted imaging, white matter fibre tracking and MR spectroscopy.

PERSPECTIVE

This study investigates the effect of smartwatch-controlled aerobic exercise on functional recovery, cognition, emotional well-being, the immune system, and neuronal network reorganization in stroke patients. Trial registration ClinicalTrials.gov NCT Number: NCT05690165. First posted19 January 2023. Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05690165.

Combined Aerobic Exercise and Virtual Reality-Based Upper Extremity Rehabilitation Intervention for Chronic Stroke: Feasibility and Preliminary Effects on Physical Function and Quality of Life

Objectives

To (1) examine the feasibility of combining lower extremity aerobic exercise (AEx) with a virtual reality (VR) upper extremity (UE) rehabilitation intervention and (2) provide an estimate of effect size for the combined intervention on UE function, aerobic capacity, and health-related quality of life.

Design

Single-group feasibility trial.

Setting

Research laboratory.

Participants

Community-dwelling individuals with mild to moderate impairment of the UE at least 6 months post stroke (N=10; male, n=6; female n=4; mean age, 54 years).

Intervention

All participants received 18 sessions over a nominal 2-3 sessions per week schedule of a combined AEx and VR-UE rehabilitation intervention. During each session, participants completed 15 minutes of lower extremity AEx followed by playing a VR-UE rehabilitation game for approximately 20 minutes.

Main Outcome Measures

Feasibility was evaluated by metrics of adherence, retention, treatment acceptability, data completeness, and adverse events. UE function, aerobic capacity (peak oxygen consumption [Vo2peak]), and quality of life were assessed with the Fugl-Meyer Assessment of Upper Extremity (FMA-UE), expired gas exchange analysis, and Stroke Impact Scale (SIS), respectively.

Results

Adherence was 100%, and there were no withdrawals or losses to follow-up to report. Participants completed the intervention in 49±14 days. Cohen's dz effect size calculations indicated the intervention elicited medium effects on FMA-UE (dz =0.50) and SIS memory domain (dz =0.46) and large effects on absolute Vo2peak (dz =1.46), relative Vo2peak (dz =1.21), SIS strength (dz =1.18), and SIS overall recovery domains (dz =0.81).

Conclusions

Combining lower extremity AEx and VR-UE rehabilitation appears feasible in the clinical research setting. Fifteen minutes of lower extremity AEx performed at vigorous intensity appears to elicit clinically meaningful benefits in chronic stroke. Further examination of the combination of lower extremity AEx and VR-UE rehabilitation and its effects on physical function and quality of life is warranted.

The effect of exercise on walking economy in patients with chronic neurological conditions: A systematic review and meta-analysis

Introduction

To investigate the effect of exercise on the walking economy (WE) of patients with chronic neurological conditions (CNCs) and to determine the type of physical activity that best improves the WE of patients with CNCs.

Methods

Four electronic databases were searched until December 2022 (Web of Science, PubMed, Cochrane, and CINAHL). Studies were screened using the following inclusion criteria: 1. randomized controlled or non-randomized controlled trials; 2. exercise interventions >4 weeks in duration; 3. patients aged ≥18 years with a diagnosis of CNCs. 4. walking economy of patients measured before and after the intervention. The PEDro scale was used to assess the methodological quality of the included studies.

Results and discussion

Twenty-two studies met the inclusion criteria. Meta-analysis results showed that exercise significantly improved WE (g = -0.352, 95% CI, -0.625 to -0.078, P = 0.012). Subgroup analysis revealed that patients who received exercise showed better WE compared with those who underwent no control intervention (g = -0.474, 95% CI, -0.636 to -0.311, P < 0.001). However, exercise therapy did not show a significant improvement of WE compared with control groups (g = -0.192, 95% CI, -0.451 to 0.067, P = 0.146). In addition, we found that endurance combined with resistance, high-intensity intermittent, and other training modalities resulted in better WE compared with the pre-intervention. Of these, interval training has the greatest effect on improving WE. In conclusion, exercise can improve WE in patients with CNCs. More randomized controlled trials are necessary for the future.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022361455, identifier: CRD42022361455.

Exercise dosage to facilitate the recovery of balance, walking, and quality of life after stroke

Background

Although aerobic training (AT) and resistance training (RT) are recommended after stroke, the optimal dosage of these interventions and their effectiveness on balance, walking capacity, and quality of life (QoL) remain conflicting.

Objectives

Our study aimed to quantify the effects of different modes, dosages and settings of exercise therapy on balance, walking capacity, and QoL in stroke survivors.

Method

PubMed, CINHAL, and Hinari databases were searched for randomised controlled trials (RCTs) evaluating the effects of AT and RT on balance, walking, and QoL in stroke survivors. The treatment effect was computed by the standard mean differences (SMDs).

Results

Twenty-eight trials (n = 1571 participants) were included. Aerobic training and RT interventions were ineffective on balance. Aerobic training interventions were the most effective in improving walking capacity (SMD = 0.37 [0.02, 0.71], p = 0.04). For walking, capacity, a higher dosage (duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve) of AT interventions demonstrated a significantly greater effect (SMD = 0.58 [0.12, 1.04], p = 0.01). Combined AT and RT improved QoL (SMD = 0.56 [0.12, 0.98], p = 0.01). Hospital located rehabilitation setting was effective for improving walking capacity (SMD = 0.57 [0.06, 1.09], p = 0.03) compared with home and/or community and laboratory settings.

Conclusion

Our findings showed that neither AT nor RT have a significant effect on balance. However, AT executed in hospital-located settings with a higher dose is a more effective strategy to facilitate walking capacity in chronic stroke. In contrast, combined AT and RT is beneficial for improving QoL.

Clinical implications

A high dosage of aerobic exercise, duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve is beneficial for improving walking capacity.

Effects of adding exercise to usual care in patients with either hypertension, type 2 diabetes or cardiovascular disease: a systematic review with meta-analysis and trial sequential analysis

Objective

To assess the beneficial and harmful effects of adding exercise to usual care for people with hypertension, type 2 diabetes mellitus and/or cardiovascular disease.

Design

Systematic review with meta-analysis and trial sequential analysis of randomised clinical trials.

Data sources

The CENTRAL, MEDLINE, EMBASE, Science Citation Index Expanded on Web of Science and BIOSIS searched from inception to July 2020.

Eligibility criteria for selecting studies

We included all randomised clinical trials adding any form of trialist defined exercise to usual care versus usual care in participants with either hypertension, type 2 diabetes or cardiovascular disease irrespective of setting, publication status, year and language.

Outcome and measures

The primary outcomes were all-cause mortality, serious adverse events and quality of life.

Data extraction and synthesis

Five independent reviewers extracted data and assessed risk of bias in pairs. Our methodology was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Grading of Recommendations Assessment, Development and Evaluation and Cochrane Risk of Bias-version 1.

Results

We included 950 trials, of which 248 trials randomising 21 633 participants reported on our predefined outcomes. All included trials were at high risk of bias. The major types of exercise reported were dynamic aerobic exercise (126/248 trials), dynamic resistance exercise (25/248 trials), and combined aerobic and resistance exercise (58/248 trials). The study participants were included due to cardiovascular diseases (189/248 trials), type 2 diabetes (41/248 trials) or hypertension (16/248 trials). The median intervention period was 3 months (IQR: 2–4 months) and the median follow-up period was 6 months (IQR: 3–8 months) after randomisation. Meta-analyses and trial sequential analyses showed evidence of a beneficial effect of adding exercise to usual care when assessing all-cause mortality (risk ratio (RR) 0.82; 95% CI 0.73 to 0.93; I2=0%, moderate certainty of evidence) and serious adverse events (RR 0.79; 95% CI 0.71 to 0.88; I2=0%, moderate certainty of evidence). We did not find evidence of a difference between trials from different economic regions, type of participants, type of exercise or duration of follow-up. Quality of life was assessed using several different tools, but the results generally showed that exercise improved quality of life, but the effect sizes were below our predefined minimal important difference.

Conclusions

A short duration of any type of exercise seems to reduce the risk of all-cause mortality and serious adverse events in patients with either hypertension, type 2 diabetes or cardiovascular diseases. Exercise seems to have statistically significant effects on quality of life, but the effect sizes seem minimal.

PROSPERO registration number

CRD42019142313.

Effect of an exercise intervention on global cognition after transient ischemic attack or minor stroke: the MoveIT randomized controlled trial

BACKGROUND

Patients with a transient ischemic attack (TIA) or ischemic stroke are at increased risk of developing cognitive impairment in the subacute phase. At present, the effects of exercise on cognitive functioning following a TIA or stroke are not fully known. The purpose of this trial was to investigate the effect of exercise on global cognition.

METHODS

The MoveIT trial is a single-centre, observer-blinded, randomized controlled trial involving a 1-year exercise intervention consisting of a 12-week group exercise program, combined with three counselling visits to the physiotherapists over a 9-month period. The control group received standard care. The primary outcome was global cognitive functioning, assessed at one year, using the Montreal Cognitive Assessment (MoCA). Secondary outcomes included cardiorespiratory fitness, the cardiovascular profile, and attainment of secondary prevention targets, anxiety, depression and fatigue at one and two years.

RESULTS

The experimental group consisted of 60 patients, while the control group consisted of 59 patients. The mean age was 64.3 years and 41% were female. No between-group differences were found on global cognitive functioning (MD, 0.7 out of 30, 95% CI, - 0.2 to 1.6) or on secondary outcome measures at 12 months. The only significant between-group difference was found for fatigue, in favour of the experimental group at 12 months (MD, 0.6 out of 63, 95% CI, 0.1 to 1.1).

CONCLUSIONS

No benefit of this exercise intervention was found regarding global cognition. Future studies need to focus on optimizing rehabilitation strategies for this vulnerable group of patients.

TRIAL REGISTRATION

http://www.trialregister.nl . Unique identifier: NL3721 . Date first registration: 06-03-2013.

Comparison of the effectiveness of anti-gravity treadmill exercises and underwater walking exercises on cardiorespiratory fitness, functional capacity and balance in stroke patients

INTRODUCTION

Aerobic exercise training after stroke has positive effects on quality of life, motor recovery, and aerobic endurance. The aim of this study was to investigate the effectiveness of anti-gravity treadmill gait training and underwater walking therapy on cardiorespiratory fitness, gait and balance in stroke survivors.

METHODS

The study included 39 patients with a history of stroke who were admitted to our center between July 2017 and January 2018. The patients were randomly assigned to anti-gravity treadmill training, underwater walking therapy, or a control group. The aerobic capacity of the participants was evaluated with the 6-min walk test and cycle ergometer testing before and after the treatment. Balance was examined using the Berg Balance Scale (BBS).

RESULTS

There was a statistically significant increase from pre- to post-treatment with regard to maximum heart rate and length of walking distance during 6-min walk test parameters in patients who underwent anti-gravity treadmill training (p < 0.05). The cycle ergometer training results showed significant improvements compared to baseline after treatment in patients who underwent anti-gravity training in terms of maximum heart rate attained during exercise stress testing, time to complete the test, rates of metabolic equivalents of task scores and peak oxygen consumption (p < 0.05). Improvements were also observed in ventricular repolarization indices including corrected QT intervals (QTc), Tp-e interval and Tp-e/QT, Tp-e/QTc ratio in the anti-gravity group (p < 0.05). BBS results showed no statistically significant difference in all groups (p > 0.05).

CONCLUSION

The data of this study showed that anti-gravity treadmill training has favorable effects on cardiorespiratory fitness in stroke survivors.

Feasibility and cost description of highly intensive rehabilitation involving new technologies in patients with post-acute stroke-a trial of the Swiss RehabTech Initiative

Background

There is a need to provide highly repetitive and intensive therapy programs for patients after stroke to improve sensorimotor impairment. The employment of technology-assisted training may facilitate access to individualized rehabilitation of high intensity. The purpose of this study was to evaluate the safety and acceptance of a high-intensity technology-assisted training for patients after stroke in the subacute or chronic phase and to establish its feasibility for a subsequent randomized controlled trial.

Methods

A longitudinal, multi-center, single-group study was conducted in four rehabilitation clinics. Patients participated in a high-intensity 4-week technology-assisted trainings consisting of 3 to 5 training days per week and at least 5 training sessions per day with a duration of 45 min each. Feasibility was evaluated by examining recruitment, intervention-related outcomes (adherence, subjectively perceived effort and effectiveness, adverse events), patient-related outcomes, and efficiency gains. Secondary outcomes focused on all three domains of the International Classification of Functioning Disability and Health. Data were analyzed and presented in a descriptive manner.

Results

In total, 14 patients after stroke were included. Participants exercised between 12 and 21 days and received between 28 and 82 (mean 46 ± 15) technology-assisted trainings during the study period, which corresponded to 2 to 7 daily interventions. Treatment was safe. No serious adverse events were reported. Minor adverse events were related to tiredness and exertion. From baseline to the end of the intervention, patients improved in several functional performance assessments of the upper and lower extremities. The efficiency gains of the trainings amounted to 10% to 58%, in particular for training of the whole body and for walking training in severely impaired patients.

Conclusions

Highly intensive technology-assisted training appears to be feasible for in- and outpatients in the subacute or chronic phase after stroke. Further clinical trials are warranted in order to define the most comprehensive approach to highly intensive technology-assisted training and to investigate its efficacy in patients with neurological disorders.

Trial registration

ClinicalTrials.gov Identifier: NCT03641651 at August 31st 2018

Effect of Physical Activity on Cognitive Impairment in Patients With Cerebrovascular Diseases: A Systematic Review and Meta-Analysis

Background and Purpose

This study investigates the effect of physical activity (PA) on cognition in patients with cerebrovascular disease and explored the maximum benefit of different PA characteristics.

Methods

Databases, such as Pubmed, Web of Science, Embase, and Cochrane Library, were searched from their inception to May 31, 2021. Standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated to generate a forest plot. In addition, subgroup analysis, moderation analysis, and regression analysis were performed to explore the possible adjustment factors.

Results

In total, 22 studies that met the criteria were included, demonstrating data from 1,601 participants. The results indicated that PA produced a positive effect on the global cognition for patients with cerebrovascular disease (SMD: 0.20 [95% CI: 0.12-0.27]), at the same time, PA training prominently improved executive function (SMD: 0.09 [95% CI: 0.00-0.17]) and working memory (SMD: 0.25 [95% CI: 0.10-0.40]). Furthermore, patients with baseline cognitive impairment received the greater benefit of PA on cognition (SMD: 0.24 [95% CI: 0.14-0.34]) than those without cognitive impairment before intervention (SMD: 0.15 [95% CI: 0.04-0.26]). For patients in the acute stage (≤ 3 months), PA did not rescue impairment dysfunction significantly (SMD: 0.08 [95% CI: -0.04-0.21]) and remarkable cognitive gains were detected in the chronic stage of participants (>3 months) (SMD: 0.25 [95% CI: 0.16-0.35]). Moderate intensity PA showed a larger pooled effect size (SMD: 0.23 [95% CI: 0.11-0.36]) than low intensity (SMD: -0.01 [95% CI: -0.44-0.43]) and high intensity (SMD: 0.16 [95% CI: 0.03-0.29]). However, the different types, duration, and frequency of PA resulted in no differences in the improvement of cognitive function. Further regression analysis demonstrated that the beneficial effects of PA on cognition are negatively correlated with age (p < 0.05).

Conclusions

This study revealed that PA can prominently improve the cognitive ability in patients with cerebrovascular diseases and strengthened the evidence that PA held promise as a widely accessible and effective non-drug therapy for vascular cognitive impairment (VCI).

Exercise for People with Acquired Brain Injury: An ICF Perspective

Exercise is an important element in the process of recovery from an acquired brain injury (ABI). However, specific guidance for exercise prescription and interventions in this population are missed. The aim of this study was to establish the key parameters to design and implement exercise programs based on the International Classification of Functioning, Disability, and Health (ICF) domains. A panel of experts that consisted of 13 professionals from neuro-rehabilitation centers evaluated the key parameters of this original proposal. The Heinemann methodology was used for all qualitative analyses. Additionally, Cronbach’s alpha was applied to the statistical analyses. According to the results, Cronbach’s alpha (0.97) indicated excellent internal consistency, and the experts perceptions ratified the proposed criteria to develop exercise programs for people with ABI. The proposed key parameters for the development of exercise programs for people with ABI based in ICF domains (body functions, activity—participation and environmental factors) bring a new, solid, and innovative tool for methodological design of these programs in sub-acute and chronic rehabilitation settings.

General and comparative self-rated health in chronic stroke: an important outcome measure for health professionals

BACKGROUND

After a stroke, several aspects of health and function may influence how individuals perceive their own health. However, self-rated health (SRH), as well as its relationship with functioning, has been little explored in individuals with stroke. The aims of this study were to determine how individuals with chronic post-stroke disabilities evaluate their health, considering general, time- and age-comparative SRH questions and to investigate whether SRH measures would be influenced by the following health and functioning domains: mental/physical functions and personal factors.

METHODS

Sixty-nine individuals with chronic post-stroke disabilities answered the three types of SRH questions and were assessed regarding depressive symptoms (emotional function domain), physical activity levels (physical function domain), and engagement in physical activity practice (personal factor domain). Subjects were divided into the following groups: good/poor for the general SRH question; better, similar, and "worse" for both time- and age-comparative questions. Between-group differences in the three domains for each SRH question were investigated (α = 5%).

RESULTS

General SRH was rated as good by 73% of the participants. Time- and age-comparative SRH was rated as better by 36% and 47% and as similar by 31% and 28% of the subjects, respectively. Significant between-group differences in emotional function were found for both the general and age-comparative questions. For the time-comparative question, significant differences were only observed for physical function.

CONCLUSION

SRH evaluation differed in individuals with chronic post-stroke disabilities according to the types of questions and health/functioning domains.

Depression in Stroke Survivors: Ten-Year Follow-Up. Determinants of the Natural Course of Depressive Symptoms in Stroke Survivors in the Netherlands: The SMART-Medea Study

OBJECTIVES

Stroke is the second most common cause of death and a major cause of disability. Besides the physical consequences, depressive symptoms are frequent in the aftermath after stroke. Every year, approximately 15 million stroke survivors worldwide are at risk of developing post-stroke depression. In this study we describe the natural course of depressive symptoms in stroke patients over a long-period of time post stroke and identify associated determinants.

MATERIALS AND METHODS

From the Second Manifestations of ARTerial disease-Memory, depression and aging (SMART-Medea) study, an observational prospective cohort study, we selected patients with cerebrovascular disease, and used the biannually collected data of the Patient Health Questionnaire-9 for depressive symptoms. A score of ≥10 indicated the presence of depressive symptoms. A multinomial logistic regression analysis was used to identify prognostic determinants for courses of depressive symptoms after stroke.

RESULTS

During a mean follow-up time of 7.9 years, 62% of the 172 participants was never depressed, 19% had a single episode and 19% had recurrent depressive symptoms. Physical function was associated with increased risk for single episode and recurrent depressive symptoms (OR=1.06 [1.01-1.11]). OR's for social, mental and (vascular) comorbidities variables were not significant. Participants' physical function was only measured at baseline. Several relevant variables were not present in this dataset, including information about clinical events during follow-up.

CONCLUSION

Nearly 40% of the participants are confronted with depressive symptoms on the long-term. Physical function plays a substantial part for stroke survivors in the development of these symptoms.

Effect of Walking Adaptability on an Uneven Surface by a Stepping Pattern on Walking Activity After Stroke

Real-world walking activity is important for poststroke patients because it leads to their participation in the community and physical activity. Walking activity may be related to adaptability to different surface conditions of the ground. The purpose of this study was to clarify whether walking adaptability on an uneven surface by step is related to daily walking activity in patients after stroke. We involved 14 patients who had hemiparesis after stroke (age: 59.4 ± 8.9 years; post-onset duration: 70.7 ± 53.5 months) and 12 healthy controls (age: 59.5 ± 14.2 years). The poststroke patients were categorized as least limited community ambulators or unlimited ambulators. For the uneven surface, the study used an artificial grass surface (7 m long, 2-cm leaf length). The subjects repeated even surface walking and the uneven surface walking trials at least two times at a comfortable speed. We collected spatiotemporal and kinematic gait parameters on both the even and uneven surfaces using a three-dimensional motion analysis system. After we measured gait, the subjects wore an accelerometer around the waist for at least 4 days. We measured the number of steps per day using the accelerometer to evaluate walking activity. Differences in gait parameters between the even and uneven surfaces were calculated to determine how the subjects adapted to an uneven surface while walking. We examined the association between the difference in parameter measurements between the two surface properties and walking activity (number of steps per day). Walking activity significantly and positively correlated with the difference in paretic step length under the conditions of different surface properties in the poststroke patients (r = 0.65, p = 0.012) and step width in the healthy controls (r = 0.68, p = 0.015). The strategy of increasing the paretic step length, but not step width, on an uneven surface may lead to a larger base of support, which maintains stability during gait on an uneven surface in poststroke patients, resulting in an increased walking activity. Therefore, in poststroke patients, an increase in paretic step length during gait on an uneven surface might be more essential for improving walking activity.

Analysis of influencing factors of rehabilitation treatment effect in patients with first-episode stroke

OBJECTIVE

To explore the influencing factors of rehabilitation treatment effect in patients with first-episode stroke and provide a theoretical basis for clinical practice.

METHODS

The clinical data of patients with first-episode stroke who received rehabilitation treatment in our hospital from January 2015 to January 2019 were collected and analyzed retrospectively. The Modified Barthel Index (MBI) and Frenchay Activity Scale (FAS) were used to evaluate the rehabilitation treatment effect. Spearman rank correlation analysis was carried out to investigate the relationship between the data characteristics and rehabilitation treatment effect, and univariate and multivariate logistic regression analyses were conducted to explore the independent factors influencing the rehabilitation treatment effect in the first-episode stroke group.

RESULTS

In this study, 786 cases of 873 patients with first-episode stroke were included, with an effective inclusion rate of 90.0%. Univariate analysis showed that MBI and FAS scores were statistically different among patients with different ages, history of hypertension, the number of residual symptoms, depression status, attitude towards rehabilitation, starting time of rehabilitation, rehabilitation treatment duration, and family environment scores (all P<0.05). According to the Spearman rank correlation analysis, age, residual symptoms, depressive status, and starting time of rehabilitation were all negatively correlated with MBI score (r = -0.584, -0.683, -0.573, -0.783) and FAS score (r = -0.438, -0.771, -0.552, -0.599), while the scores of MBI (r = 0.683, 0.572, 0.662) and FAS (r = 0.735, 0.603, 0.724) were positively correlated with the scores of rehabilitation treatment attitude, rehabilitation treatment duration and family environment (all P<0.05). Moreover, according to multivariate logistic regression analysis, age, the number of remaining symptoms, depression status, attitude towards rehabilitation treatment, starting time of rehabilitation treatment, rehabilitation treatment duration, and family environment score could independently affect MBI and FAS scores of patients with stroke (all P<0.05).

CONCLUSION

Age, the number of residual symptoms, depression status, attitude towards rehabilitation treatment, starting time of rehabilitation treatment, rehabilitation treatment duration, and family environment score are independent factors for rehabilitation treatment effect in patients with first-episode stroke.

Current practice of physical therapists in outpatient stroke rehabilitation: a cross-sectional survey in Baden-Württemberg and Thuringia / Arbeitsweise von Physiotherapeut*innen in der ambulanten Schlaganfallrehabilitation: eine Querschnittsumfrage in Baden-Württemberg und Thüringen

Objective

Guidelines recommend task-oriented training and the use of standardized assessments to improve stroke-related mobility deficits. However, the German outpatient physical therapy prescription catalogue does not include these recommendations resulting in a possible gap between guideline recommendations and clinical practice. Therefore, the purpose of this study was to describe physical therapy practice patterns of stroke-related mobility deficits in the outpatient setting exemplified by the states Baden-Württemberg and Thuringia.

Methods

Using an online survey, physical therapists treating people with stroke in outpatient settings in Baden-Württemberg and Thuringia were recruited. The questionnaire was developed using a multi-step procedure. Using a case vignette and open-ended questions, preferred evaluation and treatment methods were assessed. Data were analyzed using content analysis and descriptive statistics.

Results

Data from 63 physical therapists were included in the analysis. Answers to the open questions showed a wide range of different citations. Of 186 citations on evaluation methods, 28 (15,1 %) were classified as “standardized assessments”, while 158 citations (84,9 %) were classified as “basic physical therapy evaluation (non-standardized)”. Standardized assessments were cited by 25% of participants. Of 182 citations on treatment methods, 69 (35,2%) were classified as “traditional therapies”. These traditional therapies were cited by 81 % of participants. Task-oriented training was not cited.

Discussion

Despite the small sample size our data confirm the insufficient guideline use in German physical therapy and contribute results on practice patterns in outpatient stroke settings. These results will be used to initiate theory-based implementation strategies aiming to optimize physical therapy for people with stroke.

Users' experience of community-based power assisted exercise: a transition from NHS to third sector services

PURPOSE

Seated Power Assisted Exercise (PAE) equipment is an accessible exercise mode for people with limited mobility following stroke and is available at a small number of community-based venues. The purpose of this qualitative study was to understand the lived experience of using PAE amongst PwS in a community venue and identify recommendations for the development and advancement of PAE equipment.

METHOD

Semi-structured interviews were conducted with 8 participants (PwS) attending a community stroke venue where PAE equipment was available. Transcribed data were analysed using interpretative phenomenological analysis.

RESULTS

Three overarching themes emerged from the analysis; 1) Don't tell me I've plateaued; 2) PAE facilitates the transition into long-term recovery; 3) Reframing the experience of stroke. Participants associated the uptake of PAE alongside venue membership as a turning point in their adjustment to life following stroke. In addition, recommendations for future development of the equipment were identified.

CONCLUSION

These findings indicate that membership of a stroke venue alongside engagement with PAE facilitated transition from early stroke rehabilitation into longer term recovery. The results of this study have informed the need for future product design and highlighted PAE is an effective mode for continued rehabilitation in third-sector services.

Factors associated with met and unmet rehabilitation needs after stroke: A multicentre cohort study in Denmark and Norway

OBJECTIVES

To examine patient-reported needs for care and rehabilitation in a cohort following different subacute pathways of rehabilitation, and to explore factors underpinning met and unmet needs.

DESIGN

Observational multicentre cohort study.

PATIENTS AND METHODS

A total of 318 Norwegian and 155 Danish patients with first-ever stroke were included. Participants answered questions from the Norwegian Stroke Registry about perceived met, unmet or lack of need for help and training during the first 3 months post stroke. The term "training" in this context was used for all rehabilitative therapy offered by physiotherapists, occupational or speech therapists. The term "help" was used for care provided by health professionals.

RESULTS

Need for training: 15% reported unmet need, 52% reported met need, and 33% reported no need. Need for help: 10% reported unmet need, 58% reported met, and 31% reported no need. Participants from both Norway and Denmark had similar patterns of unmet/met need for help or training. Unmet need for training was associated with lower functioning, (odds ratio (OR) = 0.32, p < 0.05) and more anxiety (OR = 0.36, p < 0.05). Patients reporting unmet needs for help more often lived alone (OR = 0.40, p < 0.05) and were more often depressed (OR = 0.31, p < 0.05).

CONCLUSION

Similar levels of met and unmet needs for training and help at 3 months after stroke were reported despite differences in the organization of the rehabilitation services. Functioning and psychological factors were associated with unmet rehabilitation needs.

Exoskeleton-assisted walking improves pulmonary function and walking parameters among individuals with spinal cord injury: a randomized controlled pilot study

BACKGROUND

Exoskeleton-assisted walking (EAW) is expected to improve the gait of spinal cord injury (SCI) individuals. However, few studies reported the changes of pulmonary function (PF) parameters after EAW trainings. Hence, we aimed to explore the effect of EAW on PF parameters, 6-min walk test (6MWT) and lower extremity motor score (LEMS) in individuals with SCI and to compare those with conventional trainings.

METHODS

In this prospective, single-center, single-blinded randomized controlled pilot study, 18 SCI participants were randomized into the EAW group (n = 9) and conventional group (n = 9) and received 16 sessions of 50-60 min training (4 days/week, 4 weeks). Pulmonary function parameters consisting of the forced vital capacity (FVC), forced expiratory volume in 1 s (FEV₁), forced expiratory flow (FEF), peak expiratory flow, and maximal voluntary ventilation, 6MWT with assisted devices and LEMS were reported pre- and post-training.

RESULTS

Values of FVC (p = 0.041), predicted FVC% (p = 0.012) and FEV₁ (p = 0.013) were significantly greater in EAW group (FVC: 3.8 ± 1.1 L; FVC% _pred = 94.1 ± 24.5%; FEV₁: 3.5 ± 1.0 L) compared with conventional group (FVC: 2.8 ± 0.8 L; FVC% _pred = 65.4 ± 17.6%; FEV₁: 2.4 ± 0.6 L) after training. Participants in EAW group completed 6MWT with median 17.3 m while wearing the exoskeleton. There was no difference in LEMS and no adverse event.

CONCLUSIONS

The current results suggest that EAW has potential benefits to facilitate PF parameters among individuals with lower thoracic neurological level of SCI compared with conventional trainings. Additionally, robotic exoskeleton helped walking.

TRIAL REGISTRATION

Registered on 22 May 2020 at Chinese Clinical Trial Registry (ChiCTR2000033166). http://www.chictr.org.cn/edit.aspx?pid=53920&htm=4 .

Association between hand grip strength and stroke in China: a prospective cohort study

OBJECTIVES

The association between weak hand grip strength (HGS) and stroke recovery has been studied; however, few studies focused on the association of HGS with stroke prevalence and incidence.

METHODS

A prospective cohort baseline study of a nationally representative sample in Chinese adults aged 45 years and older in 2011 was followed up in 2015. 8871 participants without stroke at baseline were followed. The associations of HGS and its changes with stroke prevalence and incidence were investigated using logistic regression models and Cox proportional hazards regression models.

RESULTS

Association of HGS and stroke prevalence was significant. HGS weakness significantly increased risk of stroke incidence, with 89.3% higher risk when compared to normal HGS. During 35,263 person-years of follow-up, 112 stroke patients occurred. The four-year incidence rate ratio of stroke for participants with a HGS weakness was 2.15, compared to normal HGS participants. HGS changes in weakness/weakness from 2011 to 2015(D-HGS) and normal/weakness D-HGS had higher risks of stroke incidence when compared with those who had normal/normal D-HGS.

CONCLUSIONS

HGS weakness and decline of HGS were associated with stroke incidence for adults aged 45 years and older in China.

The Untapped Potential of Virtual Reality in Rehabilitation of Balance and Gait in Neurological Disorders

Dynamic systems theory transformed our understanding of motor control by recognizing the continual interaction between the organism and the environment. Movement could no longer be visualized simply as a response to a pattern of stimuli or as a demonstration of prior intent; movement is context dependent and is continuously reshaped by the ongoing dynamics of the world around us. Virtual reality is one methodological variable that allows us to control and manipulate that environmental context. A large body of literature exists to support the impact of visual flow, visual conditions, and visual perception on the planning and execution of movement. In rehabilitative practice, however, this technology has been employed mostly as a tool for motivation and enjoyment of physical exercise. The opportunity to modulate motor behavior through the parameters of the virtual world is often ignored in practice. In this article we present the results of experiments from our laboratories and from others demonstrating that presenting particular characteristics of the virtual world through different sensory modalities will modify balance and locomotor behavior. We will discuss how movement in the virtual world opens a window into the motor planning processes and informs us about the relative weighting of visual and somatosensory signals. Finally, we discuss how these findings should influence future treatment design.

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.

Mini Review (Part I): An Experimental Concept on Exercise and Ischemic Conditioning in Stroke Rehabilitation

Stroke remains a leading cause of adult death and disability. Poststroke rehabilitation is vital for reducing the long-term sequelae of brain ischemia. Recently, physical exercise training has been well established as an effective rehabilitation tool, but its efficacy depends on exercise parameters and the patient's capacities, which are often altered following a major cerebrovascular event. Thus, ischemic conditioning as a rehabilitation intervention was considered an “exercise equivalent,” but the investigation is still in its relative infancy. In this mini-review, we discuss the potential for physical exercise or ischemic conditioning and its relation to angiogenesis, neurogenesis, and plasticity in stroke rehabilitation. This allows the readers to understand the context of the research and the application of ischemic conditioning in poststroke rehabilitation.

The Contribution of Physical Exercise to Brain Resilience

Increasing attention has been given to understanding resilience to brain diseases, often described as brain or cognitive reserve. Among the protective factors for the development of resilience, physical activity/exercise has been considered to play an important role. Exercise is known to induce many positive effects on the brain. As such, exercise represents an important tool to influence neurodevelopment and shape the adult brain to react to life's challenges. Among many beneficial effects, exercise intervention has been associated with cognitive improvement and stress resilience in humans and animal models. Thus, a growing number of studies have demonstrated that exercise not only recovers or minimizes cognitive deficits by inducing better neuroplasticity and cognitive reserve but also counteracts brain pathology. This is evidenced before disease onset or after it has been established. In this review, we aimed to present encouraging data from current clinical and pre-clinical neuroscience research and discuss the possible biological mechanisms underlying the beneficial effects of physical exercise on resilience. We consider the implication of physical exercise for resilience from brain development to aging and for some neurological diseases. Overall, the literature indicates that brain/cognitive reserve built up by regular exercise in several stages of life, prepares the brain to be more resilient to cognitive impairment and consequently to brain pathology.

Exploring the perspectives of people post-stroke, carers and healthcare professionals to inform the development of an intervention to improve cognitive impairment post-stroke

Background: Stroke is a leading cause of death and disability worldwide. Cognitive impairment is common post-stroke and can result in negative sequalae such as a lower quality of life, increased carer burden and increased healthcare costs. Despite the prevalence and associated burden of post-stroke cognitive impairment, there is uncertainty regarding the optimum intervention to improve cognitive function post-stroke. By exploring the perspectives of people post-stroke, carers and healthcare professionals on cognitive impairment, this qualitative study aims to inform the design and development of an intervention to rehabilitate cognitive impairment post-stroke. Methods: A qualitative descriptive approach will be applied, using semi-structured interviews with people post-stroke, carers and healthcare professionals. People post-stroke will be recruited via gatekeepers from a local stroke support group and Headway, a brain injury support service. Carers will be recruited via a gatekeeper from a local carers branch. Healthcare professionals will be recruited via gatekeepers from relevant neurological sites and via Twitter. The final number of participants recruited will be guided by information power. Data will be collectively analysed and synthesised using thematic analysis. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines will be used to standardize the conduct and reporting of the research. Conclusions: It is anticipated that exploring the perspectives of people post-stroke, carers and healthcare professionals on cognitive impairment post-stroke will inform the development of an evidence-based optimal intervention to rehabilitate cognitive deficits post-stroke. This study was granted ethical approval from the Faculty of Education and Health Sciences Research Ethics Committee at the University of Limerick. Study findings will be disseminated locally through presentations at stroke support groups, as well as internationally through academic conferences and peer-reviewed journals.

Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews

BACKGROUND

Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.

METHODS

Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.

RESULTS

Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I2 = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I2 = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.

CONCLUSION

There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.

TRIAL REGISTRATION

Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.

Exercise referral to promote cardiovascular health in stroke and TIA patients: a pilot feasibility study

Objectives

Exercise programmes studied after stroke often involve specialist supervision. Determine the feasibility and safety for people with stroke (PwS) or transient ischaemic attack (TIA) participating in readily accessible, non-stroke specialised, community-based exercise programmes.

Methods

Participants were recruited into a structured, group-based, 12-week programme of aerobic and resistance exercise delivered two times per week at one of five local leisure centres. Completion rates, successful attainment of intended exercise intensity (Borg Rating of Perceived Exertion (RPE)) and safety outcomes were recorded. Measures of physical activity (International Physical Activity Questionnaire), health-related quality of life (EQ-5D) and blood pressure (BP) were recorded at baseline and day 1 post intervention.

Results

79% of participants completed >75% of the intended sessions, with >90% attainment of intended RPE. Exercise was safe with no serious and very few minor adverse events related to exercise. Exercise led to significant increases in EQ-5D (Best of Health p<0.001), levels of weekly moderate physical activity (p<0.001) and decreases in systolic BP (mean change [95% CI]=−5.4 mmHg [−2.84 to −7.96]; p<0.001).

Conclusion

Generalised exercise programmes delivered through existing local services, appears feasible, safe and may improve quality of life, physical activity and systolic BP, for PwS and TIA.

The Effect of Exercise Training on Gait, Balance, and Physical Fitness Asymmetries in Persons With Chronic Neurological Conditions: A Systematic Review of Randomized Controlled Trials

Background: Persons with chronic neurological conditions (CNCs) often present with asymmetrical impairments, creating significant differences between contralateral limbs in body functions. These asymmetries have been associated with reduced mobility and balance, and are often targeted for reduction during rehabilitation. Exercise training has established benefits for persons with CNCs, and may have positive effects on asymmetry outcomes.

Objectives: The purpose of this review was to summarize the current evidence for the effects exercise training on gait, balance, and physical fitness asymmetry in randomized control trials (RCTs) of persons with CNCs.

Methods: A search of four electronic databases (EMBASE, CINAHL, SPORTdiscus, and ovidMEDLINE) was conducted following the structured Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results: The search retrieved 3,493 articles, with 465 articles assessed for eligibly, and nine articles meeting the criteria for inclusion. Of the included articles, five incorporated resistance exercise, three incorporated aerobic exercise, and one incorporated combined exercise (i.e., resistance and aerobic exercise). Gait asymmetry improved significantly in four studies after resistance, aerobic, and combined exercise. Significant improvements in weight bearing asymmetry were reported in three studies after resistance exercise. One study reported significant improvements in both gait and balance asymmetry after resistance exercise.

Conclusions: Preliminary evidence suggests that exercise training, as a component of rehabilitation, may have positive effects on gait and balance asymmetry in persons with CNCs. Several limitations of the current literature were noted, including a limited number of studies, combination of exercise with other rehabilitation modalities, a lack of reporting on exercise prescriptions (e.g., number of repetitions, intensity), and variability in the calculation of asymmetry outcomes. These limitations prevent definitive conclusions on the effects of exercise training on asymmetry outcomes. Future trials are needed to determine the potential of exercise training for reducing asymmetry in persons with CNCs.

Learning outcomes physiotherapy in neurology – a structured consensus finding of the Austrian University Network Physiotherapy in Neurology (ÖHPN) / Learning Outcomes Physiotherapie in der Neurologie – eine strukturierte Konsensfindung des österreichischen Hochschulnetzwerkes Physiotherapie in der Neurologie (ÖHPN)

Background

European Standards and Guidelines for Quality Assurance in tertiary education at Universities of Applied Sciences recommend a high level of competence orientation. This can be achieved and evaluated by the definition of Learning Outcomes. Furthermore, these Outcomes can assure a comparison of the level of education after graduation. Efforts should be made to achieve this form of Quality Assurance for the professional education of physiotherapists.

Objective

The aim of this paper is to state consensus of the Austrian Universities of Applied Sciences Network for Physiotherapy in Neurology through the definition of shared Learning Outcomes for the field of Neurology for undergraduate physiotherapy students.

Methods

Based on the guidelines of the European Qualification Framework (EQF), Physio Austria (Austrian Association of Physiotherapists) published the competency profile for physiotherapists describing learning outcomes of EQF levels 6 as the first study cycle with Bachelor degree. Specific learning outcomes for Physiotherapy in Neurology were added for the further development and differentiated assurance of Quality Standards in coordination with experts from the Universities of Applied Sciences in Austria.

Results

In addition to the Learning Outcomes described in the competency profile of Physio Austria, this consensus paper describes those specifically for the EQF Level 6 of physiotherapy in neurology. Specifications in neurology were made for the following roles: Expert in Physiotherapy, Communicator, Teamworker, Health Promoter, Innovator, Health Professional.

Conclusion

Recommendations for quality assurance in tertiary education are actively pursued across all participating Universities of Applied Sciences. This allows a better comparability of the educational standards in Physiotherapy in Neurology in Europe as well as internationally. This is of great importance for physiotherapists as health professionals.

Reliability and validity of the incremental shuttle walking test in individuals after stroke

BACKGROUND

There are limitations to perform the cardiopulmonary exercise test (CPET) and the six-minute walking test (6MWT) in clinical settings. The incremental shuttle walking test (ISWT) might be an alternative assessment of exercise capacity and an estimation of cardiopulmonary fitness after stroke.

OBJECTIVES

To investigate the test-retest and inter-rater reliabilities, the standard error of measurement (SEM) and the minimal detectable change (MDC) of the ISWT, its construct validity to assess exercise capacity and its concurrent validity to estimate cardiopulmonary fitness after stroke.

METHODS

Prospective diagnostic accuracy study. Fifty-one individuals (54 ± 11 years) at the chronic phase (65 ± 73 months after stroke) were included. The distance walked, in meters, during the 12-stage-ISWT and the 6MWT and the peak oxygen uptake (VO_2peak, ml.kg^-1.min^-1) in the CPET (gold standard) were assessed.

RESULTS

Significant and high to very high magnitude test-retest and inter-rater reliabilities (0.88≤ICC≤0.93) of the ISWT was found. The SEM for both reliabilities was small (-23.35 m≤ SEM≤41.47 m). The MDC for test-retest and inter-rater reliabilities were 114.63 m and 64.53 m, respectively. For construct validity, a significant and high magnitude correlation between the ISWT and the 6MWT was found (ICC = 0.82). For the concurrent validity, a significant, but low magnitude correlation was found between the ISWT and the VO_2peak (rho = 0.42).

CONCLUSIONS

The ISWT demonstrated adequate reliabilities and construct validity for exercise capacity assessment. However, the concurrent validity of the ISWT as an estimation of cardiopulmonary fitness still requires further research.

Physical activity after ischemic stroke and its association with adverse outcomes: A nationwide population-based cohort study

BACKGROUND

Sufficient physical activity (PA) is highly recommended to improve the prognosis after stroke. However, there have been only a few studies evaluating the changes in PA level after stroke.

AIMS

We aimed to identify the changes in PA level between before and after stroke, and to determine the association between PA and adverse outcomes.

METHODS

This observational, retrospective cohort study was performed using  the Nationwide Health Insurance Service (NHIS) database in South Korea. Subjects between the ages of 20 to 80 years, who had a first-ever ischemic stroke from 2010 to 2013, were included. Subjects were divided into either the "sufficient" or "insufficient" subgroups, depending on the result of the self-reported PA questionnaire. Adverse outcomes, including all-cause mortality, stroke recurrence, and myocardial infarction (MI), were collected from a post-stroke health checkup to 2017.

RESULTS

Of the 34,243 subjects with ischemic stroke, only 21.24% had sufficient PA level after stroke. Among those with insufficient PA level, only 17.34% improved their PA level after stroke. Subjects with sufficient PA level after stroke, regardless of their PA level prior to stroke, showed a lower risk of composite adverse outcomes (adjusted Hazard Ratio [HR], 95% CI: 0.85, 0.80-0.90). Subjects who went from insufficient to sufficient PA level (HR 0.87, 95% CI: 0.81-0.93) showed a significantly lower risk of composite adverse outcomes.

CONCLUSIONS

Achieving a sufficient PA level after ischemic stroke appears to significantly reduce major adverse events. Further effort is needed to promote the PA level after ischemic stroke.

Adaptive robot mediated upper limb training using electromyogram-based muscle fatigue indicators

Studies on improving the adaptability of upper limb rehabilitation training do not often consider the implications of muscle fatigue sufficiently. In this study, electromyogram features were used as fatigue indicators in the context of human-robot interaction. They were utilised for auto-adaptation of the task difficulty, which resulted in a prolonged training interaction. The electromyogram data was collected from three gross-muscles of the upper limb in 30 healthy participants. The experiment followed a protocol for increasing the muscle strength by progressive strength training, that was an implementation of a known method in sports science for muscle training, in a new domain of robotic adaptation in muscle training. The study also compared how the participants in three experimental conditions perceived the change in task difficulty levels. One task benefitted from robotic adaptation (Intervention group) where the robot adjusted the task difficulty. The other two tasks were control groups 1 and 2. There was no difficulty adjustment at all in Control 1 group and the difficulty was adjusted manually in Control 2 group. The results indicated that the participants could perform a prolonged progressive strength training exercise with more repetitions with the help of a fatigue-based robotic adaptation, compared to the training interactions, which were based on manual/no adaptation. This study showed that it is possible to alter the level of the challenge using fatigue indicators, and thus, increase the interaction time. The results of the study are expected to be extended to stroke patients in the future by utilising the potential for adapting the training difficulty according to the patient's muscular state, and also to have a large number repetitions in a robot-assisted training environment.

Developing ActivABLES for community-dwelling stroke survivors using the Medical Research Council framework for complex interventions

BACKGROUND

Novel technical solutions are called for to promote home-based exercise among community-dwelling stroke survivors supported by their caregivers. Lack of resources and knowledge about how to accomplish it, has been demonstrated. The objective of this study is to describe in detail the development of ActivABLES, a technical intervention to promote home-based exercise and physical activity engagement of community-dwelling stroke survivors with support from their caregivers.

METHODS

The technical development process of ActivABLES was guided by the Medical Research Council (MRC) framework for development and evaluation of complex interventions as well as by principles of human-centred design and co-design. The main steps included: (1) Synthesis of evidence supporting the inclusion of balance exercises, mobility and walking exercises and exercises for the upper arm; (2) Implementation of initial user studies with qualitative data collection from individual interviews with stroke survivors, and focus group interviews with caregivers and health professionals; (3) Preliminary testing of eight prototypes with seven stroke survivors and their caregivers.

RESULTS

After the preliminary testing of eight prototypes, four prototypes were not further developed whereas four prototypes were modified further. In addition, two new prototypes were developed, leaving six prototypes for further modification: 1) ActivFOAM for balance exercises, 2) WalkingSTARR to facilitate walking, 3) ActivBALL for hand exercises, 4) ActivSTICKS for upper arm exercises, and 5) ActivLAMP and 6) ActivTREE which both give visual feedback on progress of daily exercise and physical activities. ActivFOAM, ActivBALL and ActivSTICKS are all connected to a tablet where exercise instructions are given. All the exercise prototypes can be connected to ActivLAMP and ActivTREE to give feedback on how much exercise the user has done. Settings can be individualised and recommended daily time and/or repetition can easily be changed as the user progresses to higher activity levels.

CONCLUSIONS

The development process of ActivABLES was guided by the principles of human-centred design, with iterative testing of future users, and by the MRC framework of complex intervention, with a repeated process of development and testing. This process resulted in six prototypes which are available for feasibility testing among a small group of community-dwelling stroke survivors.

Pharmacological Interventions and Rehabilitation Approach for Enhancing Brain Self-repair and Stroke Recovery

Neuroplasticity is a natural process occurring in the brain for the entire life. Stroke is the leading cause of long term disability and a huge medical and financial problem throughout the world. Research conducted over the past decade focused mainly on neuroprotection in the acute phase of stroke while very little studies target the chronic stage. Recovery after stroke depends on the ability of our brain to reestablish the structural and functional organization of neurovascular networks. Combining adjuvant therapies and drugs may enhance the repair processes and restore impaired brain functions. Currently, there are some drugs and rehabilitative strategies that can facilitate brain repair and improve clinical effect even years after stroke onset. Moreover, some of the compounds such as citicoline, fluoxetine, niacin, levodopa, etc. are already in clinical use or are being trialed in clinical issues. Many studies are also testing cell therapies; in our review, we focused on studies where cells have been implemented at the early stage of stroke. Next, we discuss pharmaceutical interventions. In this section, we selected methods of cognitive, behavioral, and physical rehabilitation as well as adjuvant interventions for neuroprotection including noninvasive brain stimulation and extremely low-frequency electromagnetic field. The modern rehabilitation represents a new model of physical interventions with the limited therapeutic window up to six months after stroke. However, previous studies suggest that the time window for stroke recovery is much longer than previously thought. This review attempts to present the progress in neuroprotective strategies, both pharmacological and non-pharmacological that can stimulate the endogenous neuroplasticity in post-stroke patients.

A feasibility, acceptability and fidelity study of a multifaceted behaviour change intervention targeting free-living physical activity and sedentary behaviour in community dwelling adult stroke survivors

Background

Despite the benefits of physical activity for walking ability, balance, and mood, less than 30% of stroke survivors engage in recommended levels of physical activity with high levels of sedentary behaviour observed. This study aims to assess the feasibility, acceptability and fidelity of a theory- and evidence-based multifaceted behaviour change intervention targeting free-living physical activity and sedentary behaviour after stroke.

Methods

This study will be set in community stroke services in the North East of England and will assess the feasibility of a behaviour change intervention targeting free-living physical activity and sedentary behaviour of stroke survivors and consultation behaviour of the healthcare professionals to support stroke survivors to make these lifestyle changes. Up to 35 stroke survivors currently receiving stroke rehabilitation within the study catchment area with capacity and no contraindications to increasing physical activity/reducing sedentary behaviour will be recruited. Stroke survivors will receive a supported self-management physical activity/sedentary behaviour programme incorporating provision of information, goal setting, action planning, barrier identification, coping planning, self-monitoring and feedback on physical activity and sedentary behaviour. The programme will be supported by up to 12 healthcare professionals (HCPs) recruited from the community stroke services taking part in the study. The HCPs will deliver at least two face-to-face sessions (baseline, review and subsequent reviews if necessary) and provide a range of personalised tools to support each individual stroke survivor (e.g. workbook, self-monitoring tools, information on local resources). The consultation behaviour of the HCPs will be targeted via a training programme incorporating face-to-face training, a training manual and individual feedback on intervention programme delivery from the study research team. The feasibility, acceptability and fidelity of the study protocol will be assessed.

Discussion

The most effective methods of supporting stroke survivors to alter physical activity and sedentary behaviour have yet to be established. This study will establish the feasibility of delivering a complex theory- and evidence-based intervention targeting the behaviour of both stroke survivors and HCPs and assess whether it is acceptable to the target populations. Findings will inform the iterative development of the intervention before a larger scale evaluation.

Trial registration

Trial register: Trial identifier: ISRCTN35516780, date of registration: 24/10/2018.

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.

Addition of proprioceptive neuromuscular facilitation to cardiorespiratory training in patients poststroke: study protocol for a randomized controlled trial

BACKGROUND

Individuals affected by stroke present with changes in cardiovascular and respiratory functions. Cardiorespiratory training (CRT) is one of the classic intervention guidelines for cardiorespiratory fitness. CRT in association with the proprioceptive neuromuscular facilitation (PNF) technique for respiratory muscles could improve the quality of life, cardiorespiratory function and gait parameters of patients after stroke.

OBJECTIVE

To assess the effects of respiratory and trunk patterns of CRT associated with PNF on the quality of life, gait, oxygen consumption, respiratory muscle strength and thoracic volumes.

METHODS/DESIGN

A blind, randomized clinical trial with allocation confidentiality will be performed. Forty patients will be randomized into four groups: CRT-lower limb (LL) plus PNF; CRT-LL and respiration; CRT-upper limb (UL) plus PNF; or CRT-UL and respiration. Individuals will be evaluated at three different times (pretreatment, after 20 days of treatment and 1 month after the end of treatment). The treatment protocol consists of respiratory exercises, 30 min of CRT (cycle ergometer) and then repetition of the respiratory exercises, performed three times a week over a period of 20 days. Primary outcome measures are quality of life, gait, balance, peak oxygen uptake and rib cage compartment volumes. As secondary outcomes, respiratory function and maximal inspiratory and expiratory pressures will be measured.

DISCUSSION

The association of PNF with CRT may be a viable and accessible alternative to increase cardiorespiratory function in patients with stroke.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03171012. Registered on 6 June 2017.

Adding exercise to usual care in patients with hypertension, type 2 diabetes mellitus and/or cardiovascular disease: a protocol for a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Hypertension, type 2 diabetes mellitus and cardiovascular disease are among the leading causes of mortality globally. Exercise is one of the commonly recommended interventions/preventions for hypertension, type 2 diabetes mellitus and cardiovascular disease. However, the previous reviews have shown conflicting evidence on the effects of exercise. Our objective is to assess the beneficial and harmful effects of adding exercise to usual care for people with hypertension, type 2 diabetes mellitus and/or cardiovascular disease.

METHODS

This protocol for a systematic review was undertaken using the recommendations of The Cochrane Collaboration, the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and the eight-step assessment procedure suggested by Jakobsen et al. We plan to include all relevant randomised clinical trials and cluster-randomised trials assessing the effects of adding exercise to usual care for people with hypertension, type 2 diabetes mellitus and/or cardiovascular disease. We will search the Cochrane Central Register of Controlled Trials (CENTRAL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), Latin American and Caribbean Health Sciences Literature (LILACS), Science Citation Index Expanded on Web of Science, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Chinese Science Journal Database (VIP) and BIOSIS. We will systematically assess the risks of random errors using Trial Sequential Analysis as well as risks of bias of all included trials. We will create a 'Summary of Findings' table in which we will present our primary and secondary outcomes, and we will assess the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

DISCUSSION

The present systematic review will have the potential to aid patients, clinicians and decision-makers recommending exercise and thereby, benefit patients with hypertension, type 2 diabetes mellitus and/or cardiovascular disease.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019142313.

Cost-effectiveness of physical fitness training for stroke survivors

Background Physical fitness is impaired after stroke, yet fitness training after stroke reduces disability. Several international guidelines recommend that fitness training be incorporated as part of stroke rehabilitation. However, information about cost-effectiveness is limited. Methods A decision tree model was used to estimate the cost-effectiveness of a fitness programme for stroke survivors vs. relaxation (control group). This was based on a published randomised controlled trial, from which evidence about quality of life was used to estimate Quality Adjusted Life Years. Costs were based on the cost of the provision of group fitness classes within local community centres and a cost per Quality Adjusted Life Year was calculated. Results The results of the base case analysis found an incremental cost per Quality Adjusted Life Year of £2,343. Conclusions Physical fitness sessions after stroke are a cost-effective intervention for stroke survivors. This information will help make the case for the development of new services.