Water-based exercises for improving walking speed, balance, and strength after stroke: a systematic review with meta-analyses of randomized trials

Inspiratory Training for Improving Respiratory Strength, Pulmonary Function, and Walking in Cerebral Palsy: A Meta-Analysis

PURPOSE

To investigate the effects of inspiratory strength training on respiratory muscle strength, pulmonary function, and walking capacity in children with cerebral palsy, with Gross Motor Function Classification System I to III.

METHODS

Searches were conducted in CINAHL, LILACS, MEDLINE, and Physiotherapy Evidence Database (PEDro) databases. The outcomes of interest were respiratory muscle strength, pulmonary function, and walking capacity. The quality was assessed by PEDro Scale. The Grading of Recommendations Assessment, Development, and Evaluation system was used to summarize the quality of evidence.

RESULTS

Inspiratory strength training increased the strength of inspiratory muscles and may increase the strength of the expiratory muscles. No changes were observed in pulmonary function or walking capacity.

CONCLUSIONS

This systematic review provides moderate-quality evidence that inspiratory strength training is effective for increasing inspiratory muscle strength in children with cerebral palsy. Benefits may be carried over to improving expiratory muscle strength but were not observed on pulmonary function or walking capacity.

Addition of backward walking training to forward walking training improves walking speed in children with cerebral palsy: a systematic review with meta-analysis

The objective was to examine the effects of backward walking training for improving walking speed and balance in children with cerebral palsy. A systematic review of randomized trials was conducted. Trials had to include children with cerebral palsy, with a Gross Motor Function Classification System, between I and III, that delivered backward walking training as a solo intervention or in combination with forward walking training. The outcomes of interest were walking speed and balance. The methodological quality of included trials was assessed by the PEDro scale, and the quality of evidence was assessed according to Grading of Recommendations Assessment, Development and Evaluation. Eight papers, involving 156 participants, were included. Using random-effects meta-analysis, we estimated that backward walking training improved walking speed by 0.10 m/s [95% confidence interval (CI) 0.05-0.16] and by 2 points on the Pediatric Balance Scale (0-56) (95% CI 1.5-2.2) more than forward walking training. We also estimated that the addition of backward walking training increased walking speed by 0.20 m/s (95% CI 0.07-0.34) and reduced the angular excursion of the center of gravity by 0.5 degrees (95% CI -0.7 to -0.3). The quality of the evidence was classified as low to moderate. In conclusion, overall, backward walking training appears to be as effective or slightly superior to forward walking training for improving walking speed in children with CP. The addition of backward walking training statistically significantly and clinically important enhanced benefits on walking speed.

Effectiveness of the aquatic physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in healthy community-dwelling older adults: A systematic review and meta-analysis

BACKGROUND

Opting to use aquatic or land-based physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in community-dwelling older adults (CDOAs) is still a questionable clinical decision for physiotherapists.

OBJECTIVE

Assess the quality of evidence from randomized or quasi-randomized controlled trials that used aquatic physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in CDOAs.

METHODS

Articles were surveyed in the following databases: MEDLINE/PubMed, EMBASE, SCOPUS, LILACS, Web of Science, CENTRAL (Cochrane Central Register of Controlled Trials), PEDro, CINAHL, SciELO and Google Scholar, published in any language, up to July 31, 2023. Two independent reviewers extracted the data and assessed evidence quality. The risk of bias of the trials was evaluated by the Cochrane tool and evidence quality by GRADE approach. Review Manager software was used to conduct the meta-analyses.

RESULTS

3007 articles were identified in the searches, remaining 33 studies to be read in full, with 11 trials being eligible for this systematic review. The trials included presented low evidence quality for the balance, gait, quality of life and fear of falling. Land-based and aquatic physical therapy exercises improved the outcomes analyzed; however, aquatic physical therapy exercises were more effective in improving balance, gait, quality of life and reducing fear of falling in CDOAs. The meta-analysis showed that engaging in aquatic physical therapy exercises increases the functional reach, through of the anterior displacement of the center of pressure of CDOAs by 6.36cm, compared to land-based physical therapy exercises, assessed by the Functional Reach test: [CI:5.22 to 7.50], (p<0.00001), presenting low quality evidence.

CONCLUSIONS

Aquatic physical therapy exercises are more effective than their land-based counterparts in enhancing balance, gait, quality of life and reducing the fear of falling in CDOAs. However, due to methodological limitations of the trials, this clinical decision remains inconclusive. It is suggested that new trials be conducted with greater methodological rigor, in order to provide high-quality evidence on the use of the aquatic physical therapy exercises to improve the outcomes analyzed in CDOAs.

Brazilian practice guidelines for stroke rehabilitation: Part II

The Brazilian Practice Guidelines for Stroke Rehabilitation - Part II, developed by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, in Portuguese), focuses on specific rehabilitation techniques to aid recovery from impairment and disability after stroke. As in Part I, Part II is also based on recently available evidence from randomized controlled trials, systematic reviews, meta-analyses, and other guidelines. Part II covers disorders of communication, dysphagia, postural control and balance, ataxias, spasticity, upper limb rehabilitation, gait, cognition, unilateral spatial neglect, sensory impairments, home rehabilitation, medication adherence, palliative care, cerebrovascular events related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the future of stroke rehabilitation, and stroke websites to support patients and caregivers. Our goal is to provide health professionals with more recent knowledge and recommendations for better rehabilitation care after stroke.

Walking speed and home adaptations are associated with independence after stroke: a population-based prevalence study

This study aimed at estimating the prevalence of stroke in older adults in Brazil, and at identifying the sociodemographic, health-related, health service-related, and environmental factors associated with independence in daily activities. Across-sectional, population-based study (Brazilian Longitudinal Study of Aging 2015-2016) was conducted. 536 individuals (≥ 50 years), from 9,412 participants, have had stroke and were included. Prevalence of stroke was 5.3% among individuals aged 50 years and over, increasing up to 8.0% among individuals aged 75 years and over, showing a dissimilar pattern between sex. Independence was associated with walking speed (Prevalence Ratio (PR) 2.72, 95%CI: 1.96 to 3.77), physical activity (PR 1.24; 95%CI: 1.04 to 1.47) and use of walking devices (PR 0.63; 95%CI: 0.41 to 0.96). A significant interaction was found between walking speed plus home adaptations and performance of daily living activities (PR 3.42; 95%CI: 1.04 to 11.29). The probability of independence was 40% among slow walkers (< 0.4 m/s), increasing up to 70% among fast walkers (> 0.8 m/s), and to 90% among those who also have home adaptations. Faster walking speed combined with home adaptations was the main factor associated with long-term independence after stroke.

Evaluation of quality of life in individuals with chronic stroke who underwent aquatic exercises: A case series

BACKGROUND

Aquatic exercises are among the treatments available to improve the quality of life after stroke.

OBJECTIVES

To investigate changes in the quality of life after 8-week of aquatic exercises in post-stroke individuals.

METHODS

A case series study was designed, including four male participants. Exclusive aquatic exercise was performed for 8-week, 50 minutes per session, 2×/week. Their quality of life was evaluated before and after the intervention using the Stroke Impact Scale (SIS).

RESULTS

Participant 1 improved in the mobility domain, achieving a Clinically Important Difference (CID). Participant 2 improved in the strength and mobility domain, achieving CID; his stroke recovery was 6%, and it reached 50% post-intervention. Participant 3 improved in the mobility domain, achieving a CID and a Minimal Detectable Change (MDC); his stroke recovery increased from 45 to 60% post-intervention. Participant 4 improved the strength, mobility, and activities of daily living domains, achieving a CID and a MDC, but his stroke recovery remained unchanged at 80%.

CONCLUSIONS

All participants achieved a CID in the mobility domain; thus, the aquatic exercise intervention was considered meaningful. Moreover, the SIS is able to evaluate aspects of the recovery process regarding health-related quality of life after stroke, as demonstrated by the results of the overall recovery after aquatic exercises.

Treadmill walking improves walking speed and distance in ambulatory people after stroke and is not inferior to overground walking: a systematic review

QUESTIONS

Does mechanically assisted walking improve walking speed, distance and participation compared with no/non-walking intervention or overground walking after stroke? Are any benefits maintained beyond the intervention period?

DESIGN

Systematic review of randomised trials with meta-analysis.

PARTICIPANTS

Ambulatory adults at any time after stroke.

INTERVENTION

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

OUTCOME MEASURES

Walking speed, walking distance and participation.

RESULTS

Sixteen trials involving 713 participants were included. The mean PEDro score of the trials was 6.3 (range 4 to 8). Treadmill walking increased walking speed by 0.13 m/s (95% CI 0.08 to 0.19) and distance by 46 m (95% CI 24 to 68) compared with no/non-walking intervention; these effects were largely maintained beyond the intervention. Treadmill walking had a similar or better effect on walking speed (MD 0.07 m/s, 95% CI 0.00 to 0.13) and distance (MD 18 m, 95% CI 1 to 36) compared with overground walking. The estimate of the relative effect of treadmill walking compared with overground walking on participation was very imprecise (SMD 0.16, 95% CI -0.15 to 0.48).

CONCLUSION

This systematic review provides moderate-quality evidence that the effect of treadmill walking is the same as or better than the effect of overground walking for improving walking speed and distance in ambulatory people after stroke. Long-term effects and carryover benefits to participation remain uncertain.

REVIEW REGISTRATION

PROSPERO (CRD42020162778).

Evaluation of the Feasibility of a Two-Week Course of Aquatic Therapy and Thalassotherapy in a Mild Post-Stroke Population

Strokes are a leading cause of disability in developed countries. Patients with disabilities need rehabilitation to improve their physical functioning, mental status, and quality of life. Currently, no high-quality evidence can be found attesting the benefits of any of the interventions that are nowadays used. Water-based exercise may improve the physical conditions and quality of life of people in the post-stroke phase. The objective of this study is to test whether aquatic therapy in an enriched environment at the seaside (a thalassotherapy center) could play a role in this condition. A quasi-experimental prospective study consisting of a specific program assessed 62 patients with a mild–moderate disability pre- and post-2 weeks of intensive treatment. They followed a thalassotherapy regimen including aquatic therapy in a sea water pool at 32–34 °C for 45 min daily five times a week. The outcomes measured were the Berg Balance scale, the Timed Up and Go test, the 10-meter walking test, the 6-min walking test, the Pain Visual Analogue Scale, the WHO Well-being index, EuroQoL VAS and EuroQoL 5D. We observed a significant improvement in all outcomes measured (p < 0.001, except mobility EuroQoL p < 0.05), except in the other four dimensions of the EuroQoL 5D and 10-metre walking test (NS). Conclusion: A two-week intensive course of aquatic therapy and thalassotherapy may be beneficial in the short term by reducing pain and improving the functional status and overall well-being of post-stroke patients.

Ankle-foot orthoses and continuous functional electrical stimulation improve walking speed after stroke: a systematic review and meta-analyses of randomized controlled trials

BACKGROUND

Foot-drop is a common impairment after stroke, which reduces walking ability.

OBJECTIVE

To examine the efficacy of interventions aimed at reducing foot-drop, i.e., ankle-foot orthoses and functional electrical stimulation, on walking speed and balance after stroke.

DATA SOURCES

MEDLINE, EMBASE, Cochrane, PsycINFO, and PEDro databases.

ELIGIBILITY CRITERIA

The review included only parallel, randomized trials. Participants were ambulatory adults after stroke. The experimental interventions were the use of an ankle-foot orthosis or functional electrical stimulation.

DATA SYNTHESIS

Outcome data related to walking speed and balance were extracted from the eligible trials and combined in random-effects meta-analyses. The quality of trials was assessed by the PEDro scores and the quality of evidence was determined according the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

Eleven trials involving 1135 participants were included. The mean PEDro score of the trials was 5.8 (ranging from 4 to 7). Ankle-foot orthoses (MD 0.24m/s; 95% CI 0.06 to 0.41) and functional electrical stimulation (MD 0.09m/s; 95% CI 0.03 to 0.14) significantly increased walking speed, compared with no intervention/placebo. Results regarding balance were inconclusive. Ankle-foot orthoses were not superior to functional electrical stimulation for improving walking speed (MD 0.00m/s; 95% CI -0.06 to 0.05) or balance (MD 0.27 points on the Berg Balance Scale; 95% CI -0.85 to 1.39) after stroke.

CONCLUSIONS

This systematic review provided moderate-quality evidence that both ankle-foot orthoses and functional electrical stimulation improve walking speed after stroke, but the effects on balance remain unclear.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019130988.