Treadmill aerobic exercise training reduces the energy expenditure and cardiovascular demands of hemiparetic gait in chronic stroke patients. A preliminary report

Reproducibility (reliability and agreement) of ventilatory threshold and peak responses during cardiopulmonary exercise test in people with stroke

BACKGROUND

A cardiopulmonary exercise test (CPET) is used to determine the ventilatory thresholds and to directly assess cardiorespiratory capacity. However, its reproducibility should be tested in people with stroke as sequelae imposed by the stroke may induce important variations among and within each subject, affecting the reproducibility of the physiological responses to CPET.

PURPOSE

This cross-sectional repeated measures study design aims to determine the reproducibility of anaerobic threshold (AT), respiratory compensation point (RCP), and maximal cardiorespiratory capacity assessed during a CPET in people with stroke.

METHODS

Twenty-eight subjects with hemiparesis after stroke aging 60 ± 13 years were submitted to two treadmill CPETs with identical protocols.

DATA ANALYSIS

The reproducibility of heart rate (HR) and oxygen consumption (VO2) obtained at AT, RCP, and peak effort was evaluated by systematic error (paired t-test); reliability (ICC and 95% confidence interval); and agreement (typical error and coefficient of variation).

RESULTS

There were no systematic errors for HR and VO2assessed at AT, RCP, and peak effort (p  > 0,05). Reliability was high for these variables during CPET (ICCs > 0.93). Agreement was good for all variables. Typical errors for HR and VO2 assessed at AT, RCP, and peak effort were, respectively, 7, 7, and 8 bpm, and 1.51, 1.44, and 1.57 ml.kg-1.min-1. Coefficients of variation assessed at AT, RCP, and peak effort were, respectively, 5.7, 5.1, and 6.0% for HR and 8.7, 7.3, and 7.5% for VO2.

CONCLUSIONS

HR and VO2 measured at AT, RCP, and peak effort during a treadmill CPET present good reproducibility in people with stroke, showing high reliability and good agreement.

Effect of low-level laser therapy on quadriceps and foot muscle fatigue in children with spastic diplegia: a randomized controlled study

Spastic diplegia is the most common form of cerebral palsy; children with spastic diplegia are suffering from muscle fatigue and spasticity which lead to decreasing power of muscles, impaired motor control, and many functional abilities. The effect of low-level laser (LLL) has a good result as it improves muscles pain and spasticity and in decreasing lactate levels. Forty children were selected with spastic diplegia and were divided into two groups: A and B. Group A received low-level laser treatment (LLLT) with physiotherapy treatment. Group B got physiotherapy sessions. Pain intensity was assessed by the visual analog scale (VAS) of pain which is reliable from age 5, before treatment and after 1-month follow-up. Muscle fatigue and power were assessed by maximum voluntary isometric contraction (MVIC) before treatment and after 1-month follow-up. Also, we tested blood lactate level in both groups; all evaluations were done before treatment and after 1-month follow-up. We found a significant difference between the two groups in VAS and MVIC and blood lactate level test regarding low-level therapy after 1-month follow-up. There is a good effect of low-level laser in increasing muscle power, decreasing blood lactate level, and improving pain.

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.

Associations Between Time After Stroke and Exercise Training Outcomes: A Meta-Regression Analysis

Background Knowledge gaps exist regarding the effect of time elapsed after stroke on the effectiveness of exercise training interventions, offering incomplete guidance to clinicians. Methods and Results To determine the associations between time after stroke and 6-minute walk distance, 10-meter walk time, cardiorespiratory fitness and balance (Berg Balance Scale score [BBS]) in exercise training interventions, relevant studies in post-stroke populations were identified by systematic review. Time after stroke as continuous or dichotomized (≤3 months versus >3 months, and ≤6 months versus >6 months) variables and weighted mean differences in postintervention outcomes were examined in meta-regression analyses adjusted for study baseline mean values (pre-post comparisons) or baseline mean values and baseline control-intervention differences (controlled comparisons). Secondary models were adjusted additionally for mean age, sex, and aerobic exercise intensity, dose, and modality. We included 148 studies. Earlier exercise training initiation was associated with larger pre-post differences in mobility; studies initiated ≤3 months versus >3 months after stroke were associated with larger differences (weighted mean differences [95% confidence interval]) in 6-minute walk distance (36.3 meters; 95% CI, 14.2-58.5), comfortable 10-meter walk time (0.13 m/s; 95% CI, 0.06-0.19) and fast 10-meter walk time (0.16 m/s; 95% CI, 0.03-0.3), in fully adjusted models. Initiation ≤3 months versus >3 months was not associated with cardiorespiratory fitness but was associated with a higher but not clinically important Berg Balance Scale score difference (2.9 points; 95% CI, 0.41-5.5). In exercise training versus control studies, initiation ≤3 months was associated with a greater difference in only postintervention 6-minute walk distance (baseline-adjusted 27.3 meters; 95% CI, 6.1-48.5; fully adjusted, 24.9 meters; 95% CI, 0.82-49.1; a similar association was seen for ≤6 months versus >6 months after stroke (fully adjusted, 26.6 meters; 95% CI, 2.6-50.6). Conclusions There may be a clinically meaningful benefit to mobility outcomes when exercise is initiated within 3 months and up to 6 months after stroke.

Moderate-intensity exercise versus high-intensity interval training to recover walking post-stroke: protocol for a randomized controlled trial

Background

Stroke results in neurologic impairments and aerobic deconditioning that contribute to limited walking capacity which is a major barrier post-stroke. Current exercise recommendations and stroke rehabilitation guidelines recommend moderate-intensity aerobic training post-stroke. Locomotor high-intensity interval training is a promising new strategy that has shown significantly greater improvements in aerobic fitness and motor performance than moderate-intensity aerobic training in other populations. However, the relative benefits and risks of high-intensity interval training and moderate-intensity aerobic training remain poorly understood following stroke. In this study, we hypothesize that locomotor high-intensity interval training will result in greater improvements in walking capacity than moderate-intensity aerobic training.

Methods

Using a single-blind, 3-site randomized controlled trial, 50 chronic (> 6 months) stroke survivors are randomly assigned to complete 36 locomotor training sessions of either high-intensity interval training or moderate-intensity aerobic training. Main eligibility criteria are age 40–80 years, single stroke for which the participant received treatment (experienced 6 months to 5 years prior to consent), walking speed ≤ 1.0 m/s, able to walk at least 3 min on the treadmill at ≥ 0.13 m/s (0.3 mph), stable cardiovascular condition (American Heart Association class B), and the ability to walk 10 m overground without continuous physical assistance. The primary outcome (walking capacity) and secondary outcomes (self-selected and fast gait speed, aerobic fitness, and fatigue) are assessed prior to initiating training and after 4 weeks, 8 weeks, and 12 weeks of training.

Discussion

This study will provide fundamental new knowledge to inform the selection of intensity and duration dosing parameters for gait recovery and optimization of aerobic training interventions in chronic stroke. Data needed to justify and design a subsequent definitive trial will also be obtained. Thus, the results of this study will inform future stroke rehabilitation guidelines on how to optimally improve walking capacity following stroke.

Trial registration

ClinicalTrials.govNCT03760016. Registered on November 30, 2018.

Exercise Training for Patients With Severe Aortic Stenosis in a Convalescent Rehabilitation Ward - A Retrospective Cohort Study

Background: Exercise loading is contraindicated for patients with severe aortic stenosis (AS); however, everyday activities mandate the inclusion of a light load. The aim of this study was to investigate the efficacy and safety of exercise training for patients with severe AS who were admitted to a rehabilitation ward because of physical disability. Methods and Results: This historical cohort study was conducted at a single rehabilitation center in Japan. Patients admitted for rehabilitation of physical disability and those who met the definition of severe AS were analyzed. An exercise training program was implemented for patients with disability and severe AS. Cardiovascular symptoms during hospitalization were evaluated. Improvements in the performance of activities of daily living were assessed using the Functional Independence Measure (FIM). Eighteen patients undertook an exercise training program. The median patient age was 87 years (range 76-95 years). Of these patients, 3 died and another 3 were transferred to another hospital due to causes other than the exercise training program. None of the other patients experienced cardiovascular symptoms, and the FIM scores of 12 patients were significantly improved (median [range] scores at admission and discharge of 63 [32-88] and 87 [51-104], respectively; P<0.001). Conclusions: An exercise training program could be applied to patients with severe AS who were admitted for convalescent rehabilitation, because it can improve FIM scores.

The Value of High Intensity Locomotor Training Applied to Patients With Acute-Onset Neurologic Injury

Long-standing research in animal models and humans with stroke or incomplete spinal cord injury (iSCI) indicate that specific physical training variables, such as the specificity and amount of practice, may influence neurologic recovery and locomotor function. More recent data highlight the contributions of exercise intensity, as estimated indirectly by cardiovascular exertion, as potentially more important than previously considered. The effects of exercise intensity are well described in neurologically intact individuals, although confusion regarding the definitions of intensity and safety concerns have limited its implementation during physical rehabilitation of patients with neurologic injury. The purpose of this review is to delineate some of the evidence regarding the effects of exercise intensity during locomotor training in patients with stroke and iSCI. We provide specific definitions of exercise intensity used within the literature, describe methods used to ensure appropriate levels of exertion, and discuss potential adverse events and safety concerns during its application. Further details on the effects of locomotor training intensity on clinical outcomes, and on neuromuscular and cardiovascular function will be addressed as available. Existing literature across multiple studies and meta-analyses reveals that exercise training intensity is likely a major factor that can influence locomotor function after neurologic injury. To extend these findings, we describe previous attempts to implement moderate to high intensity interventions during physical rehabilitation of patients with neurologic injury, including the utility of specific strategies to facilitate implementation, and to navigate potential barriers that may arise during implementation efforts.

Insulin Resistance in Skeletal Muscle of Chronic Stroke

A stroke can lead to reduced mobility affecting skeletal muscle mass and fatty infiltration which could lead to systemic insulin resistance, but this has not been examined and the mechanisms are currently unknown. The objective was to compare the effects of in vivo insulin on skeletal muscle glycogen synthase (GS) activity in paretic (P) and nonparetic (NP) skeletal muscle in chronic stroke, and to compare to nonstroke controls. Participants were mild to moderately disabled adults with chronic stroke (n = 30, 60 ± 8 years) and sedentary controls (n = 35, 62 ± 8 years). Insulin sensitivity (M) and bilateral GS activity were determined after an overnight fast and during a hyperinsulinemic-euglycemic clamp. Stroke subjects had lower aerobic capacity than controls, but M was not significantly different. Insulin-stimulated activities of GS (independent, total, fractional), as well as absolute differences (insulin minus basal) and the percent change (insulin minus basal, relative to basal) in GS activities, were all significantly lower in P versus NP muscle. Basal GS fractional activity was 3-fold higher, and the increase in GS fractional activity during the clamp was 2-fold higher in control versus P and NP muscle. Visceral fat and intermuscular fat were associated with lower M. The effect of in vivo insulin to increase GS fractional activity was associated with M in control and P muscle. A reduction in insulin action on GS in paretic muscle likely contributes to skeletal muscle-specific insulin resistance in chronic stroke.

The Effect of Stroke on Middle Cerebral Artery Blood Flow Velocity Dynamics During Exercise

BACKGROUND AND PURPOSE

Previous work demonstrates that older adults have a lower response in the middle cerebral artery velocity (MCAv) to an acute bout of moderate-intensity exercise when compared with young adults. However, no information exists regarding MCAv response to exercise after stroke. We tested whether MCAv response to an acute bout of moderate-intensity exercise differed between participants 3 months after stroke and an age- and sex-matched control group of older adults (CON). A secondary objective was to compare MCAv response between the stroke- and non-stroke-affected MCAv.

METHODS

Using transcranial Doppler ultrasound, we recorded MCAv during a 90-second baseline (BL) followed by a 6-minute moderate-intensity exercise bout using a recumbent stepper. Heart rate (HR), end-tidal CO2 (PETCO2), and beat-to-beat mean arterial blood pressure (MAP) were additional variables of interest. The MCAv response measures included BL, peak response amplitude (Amp), time delay (TD), and time constant (τ).

RESULTS

The Amp was significantly lower in the stroke-affected MCAv compared with CON (P < 0.01) and in the nonaffected MCAv compared with CON (P = 0.03). No between-group differences were found between TD and τ. No significant differences were found during exercise for PETCO2 and MAP while HR was lower in participants with stroke (P < 0.01). Within the group of participants with stroke, no differences were found between the stroke-affected and non-stroke-affected sides for any measures.

DISCUSSION AND CONCLUSIONS

Resolution of the dynamic response profile has the potential to increase our understanding of the cerebrovascular control mechanisms and test cerebrovascular response to physical therapy-driven interventions such as exercise.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A284).

WITHDRAWN: Immediate Adaptations to Poststroke Walking Performance Using a Wearable Robotic Exoskeleton

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Factors That Contribute to the Use of Stroke Self-Rehabilitation Technologies: A Review

Background

Stroke is increasingly one of the main causes of impairment and disability. Contextual and empirical evidence demonstrate that, mainly due to service delivery constraints, but also due to a move toward personalized health care in the comfort of patients’ homes, more stroke survivors undergo rehabilitation at home with minimal or no supervision. Due to this trend toward telerehabilitation, systems for stroke patient self-rehabilitation have become increasingly popular, with many solutions recently proposed based on technological advances in sensing, machine learning, and visualization. However, by targeting generic patient profiles, these systems often do not provide adequate rehabilitation service, as they are not tailored to specific patients’ needs.

Objective

Our objective was to review state-of-the-art home rehabilitation systems and discuss their effectiveness from a patient-centric perspective. We aimed to analyze engagement enhancement of self-rehabilitation systems, as well as motivation, to identify the challenges in technology uptake.

Methods

We performed a systematic literature search with 307,550 results. Then, through a narrative review, we selected 96 sources of existing home rehabilitation systems and we conducted a critical analysis. Based on the critical analysis, we formulated new criteria to be used when designing future solutions, addressing the need for increased patient involvement and individualism. We categorized the criteria based on (1) motivation, (2) acceptance, and (3) technological aspects affecting the incorporation of the technology in practice. We categorized all reviewed systems based on whether they successfully met each of the proposed criteria.

Results

The criteria we identified were nonintrusive, nonwearable, motivation and engagement enhancing, individualized, supporting daily activities, cost-effective, simple, and transferable. We also examined the motivation method, suitability for elderly patients, and intended use as supplementary criteria. Through the detailed literature review and comparative analysis, we found no system reported in the literature that addressed all the set criteria. Most systems successfully addressed a subset of the criteria, but none successfully addressed all set goals of the ideal self-rehabilitation system for home use.

Conclusions

We identified a gap in the state-of-the-art in telerehabilitation and propose a set of criteria for a novel patient-centric system to enhance patient engagement and motivation and deliver better self-rehabilitation commitment.

Preventing Muscle Atrophy Following Strokes: A Reappraisal

Muscle atrophy leading to muscle weakness accounts for major cause of disabilities among stroke survivors. It amounts to compromised gait and prevails to viscous cycle of diminished physical capacities and compromised participation in rehabilitative tasks. There is predisposition to recurrent strokes due to added risk of developing metabolic syndrome. Therefore, beyond the shadow of doubt, there is ripple effect of rehabilitation and thereby muscle protection in these subsets of patients. Herein, we highlight upon the newer insights with regard to preventing muscle atrophy following strokes.

Frequency-specific functional connectivity related to the rehabilitation task of stroke patients

PURPOSES

Stroke survivors suffering from deficits in motor control typically show persistent motor symptoms and limited functional abilities, which affect their functional independence in daily life. Active rehabilitation training is commonly applied for stroke patients to recover from motor dysfunction. The global connectivity reflects the synchronization of cardiac and respiratory activities in the cerebral regions. However, the understanding of the patterns of frequency-specific global connectivity (GC) and functional connectivity (FC) when performing active rehabilitation training is still far from comprehensive. This study was conducted to investigate the brain network patterns of stroke patients while performing a four-limb linkage rehabilitation training using the functional near-infrared spectroscopy (fNIRS) method.

METHODS

Two groups of stroke patients (LH, left hemiplegia; RH, right hemiplegia) and one healthy group were recruited to participate in this study. The wavelet phase coherence (WPCO) method was used to calculate the frequency-specific GC and FC of the brain network in four frequency bands: I, 0.6-2 Hz; II, 0.145-0.6 Hz; III, 0.052-0.145 Hz; and IV, 0.021-0.052 Hz.

RESULTS

Results showed that the healthy group exhibited lower WPCO in the four frequency bands during the task state than during the resting state (P < 0.05). Interestingly, the stroke groups showed increased WPCO in the frequency band II during the task state than during the resting state (P < 0.05). Moreover, significantly lower WPCO values in the frequency bands III (P < 0.05) were found during task state in the RH and LH groups compared with the healthy group. The RH group showed increased WPCO values in the frequency band II during the task state compared with the healthy group (P < 0.05). In addition, the RH group showed increased WPCO in the frequency bands I (P < 0.05) and II (P < 0.05) than the LH group. Notably, the rehabilitation task did not induce significant changes in stroke groups in the frequency band IV, which implied the neurogenic activity.

CONCLUSIONS

The reductions in FC suggested that the brain impairments caused a disturbed neurovascular coupling regulation in stroke patients. Results in frequency band IV suggested that the limb movement rehabilitation task intrinsically may not produce remarkable effect on the neurogenic activity of stroke patients. Significant differences in WPCO between the LH and RH groups suggested that the rehabilitation task should be specifically designed for individual rehabilitation. The frequency-specific FC methods based on WPCO would provide a potential approach to quantitatively assess the effect of rehabilitation tasks.

Rhythmic arm swing integrated into treadmill training in patients with chronic stroke: A single-subject experimental study

Normal walking includes coordinated and controlled movement of the legs and arms. However, patients following stroke often present with inappropriate motor control which limits coordinated movement patterns of the affected limbs. This study aimed to compare the effects of rhythmic arm swing and arm fixation during treadmill walking in patients with poststroke hemiparesis. We used an alternating study design with multiple baselines across subjects. Three patients with chronic stroke participated in this study. During treadmill walking, rhythmic arm swing and arm fixation conditions were alternately applied. Outcome measures included the 10-meter walk test (10MWT) and energy expenditure index (EEI). In the intervention phase, all subjects showed significantly greater improvements in the 10MWT and EEI scores for rhythmic arm swing condition compared to those for arm fixation condition (p < 0.05). 10MWT improvement rates: Subject 1-34.81% vs. 15.75%; Subject 2-40.00% vs. 17.95%; and Subject 3-38.08% vs. 21.85%; and EEI improvements: Subject 1-23.19% vs. 14.08%; Subject 2-26.15% vs. 20.43%; and Subject 3-22.99% vs. 14.49%. These findings suggest that rhythmic arm swing is clinically feasible as a more favorable option to enhance the effects of treadmill walking training. However, larger studies with a different study design are needed to be able to make any judgment about the usefulness of the treatment.

Oxygen uptake during functional activities after stroke-Reliability and validity of a portable ergospirometry system

Background

People with stroke have a low peak aerobic capacity and experience increased effort during performance of daily activities. The purpose of this study was to examine test-retest reliability of a portable ergospirometry system in people with stroke during performance of functional activities in a field-test. Secondary aims were to examine the proportion of oxygen consumed during the field-test in relation to the peak-test and to analyse the correlation between the oxygen uptake during the field-test and peak-test in order to support the validity of the field-test.

Methods

With simultaneous measurement of oxygen consumption, participants performed a standardized field-test consisting of five activities; walking over ground, stair walking, stepping over obstacles, walking slalom between cones and from a standing position lifting objects from one height to another. All activities were performed in self-selected speed. Prior to the field-test, a peak aerobic capacity test was performed. The field-test was repeated minimum 2 and maximum 14 days between the tests. ICC_2,1 and Bland Altman tests (Limits of Agreement, LoA) were used to analyse test-retest reliability.

Results

In total 31 participants (39% women, mean (SD) age 54.5 (12.7) years and 21.1 (14.3) months’ post-stroke) were included. The ICC_2,1 was ≥ 0.80 for absolute V̇O₂, relative V̇O₂, minute ventilation, CO₂, respiratory exchange ratio, heart rate and Borgs rating of perceived exertion. ICC_2,1 for total time to complete the field-test was 0.99. Mean difference in steady state V̇O₂ during Test 1 and Test 2 was -0.40 (2.12) The LoAs were -3.75 and 4.51. Participants spent 60.7% of their V̇O₂peak performing functional activities. Correlation between field-test and peak-test was 0.689, p = 0.001 for absolute and 0.733, p = 0.001 for relative V̇O₂.

Conclusions

This study presents first evidence on reliability of oxygen uptake during performance of functional activities after stroke, showing very good test-retest reliability. The secondary analysis showed that the amount of energy spent during the field-test relative to the peak-test was high and the correlation between the two test was good, supporting the validity of this method.

Alterations in Aerobic Exercise Performance and Gait Economy Following High-Intensity Dynamic Stepping Training in Persons With Subacute Stroke

BACKGROUND AND PURPOSE

Impairments in metabolic capacity and economy (O2cost) are hallmark characteristics of locomotor dysfunction following stroke. High-intensity (aerobic) training has been shown to improve peak oxygen consumption in this population, with fewer reports of changes in O2cost. However, particularly in persons with subacute stroke, inconsistent gains in walking function are observed with minimal associations with gains in metabolic parameters. The purpose of this study was to evaluate changes in aerobic exercise performance in participants with subacute stroke following high-intensity variable stepping training as compared with conventional therapy.

METHODS

A secondary analysis was performed on data from a randomized controlled trial comparing high-intensity training with conventional interventions, and from the pilot study that formed the basis for the randomized controlled trial. Participants 1 to 6 months poststroke received 40 or fewer sessions of high-intensity variable stepping training (n = 21) or conventional interventions (n = 12). Assessments were performed at baseline (BSL), posttraining, and 2- to 3-month follow-up and included changes in submaximal (Equation is included in full-text article.)O2 ((Equation is included in full-text article.)O2submax) and O2cost at fastest possible treadmill speeds and peak speeds at BSL testing.

RESULTS

Significant improvements were observed in (Equation is included in full-text article.)O2submax with less consistent improvements in O2cost, although individual responses varied substantially. Combined changes in both (Equation is included in full-text article.)O2submax and (Equation is included in full-text article.)O2 at matched peak BSL speeds revealed stronger correlations to improvements in walking function as compared with either measure alone.

DISCUSSION AND CONCLUSIONS

High-intensity stepping training may elicit significant improvements in (Equation is included in full-text article.)O2submax, whereas changes in both peak capacity and economy better reflect gains in walking function. Providing high-intensity training to improve locomotor and aerobic exercise performance may increase the efficiency of rehabilitation sessions.Video Abstract available for more insights from the authors (see Supplemental Digital Content, http://links.lww.com/JNPT/A142).

POWER training in chronic stroke individuals: differences between responders and nonresponders

BACKGROUND

Lower extremity muscle weakness is a primary contributor to post-stroke dysfunction. Resistance training is an effective treatment for hemiparetic weakness and improves walking performance. Post-stroke subject characteristics that do or do not improve walking speed following resistance training are unknown.

OBJECTIVE

The purpose of this paper was to describe baseline characteristics, as well as responses to training, associated with achieving a minimal clinically important difference (MCID) in walking speed (≥0.16 m/s) following Post-stroke Optimization of Walking Using Explosive Resistance (POWER) training.

METHODS

Seventeen participants completed 24 sessions of POWER training, which included intensive progressive leg presses, jump training, calf raises, sit-to-stands, step-ups, and over ground fast walking. Outcomes included SSWS, FCWS, DGI, FMA-LE, 6-MWT, paretic knee power, non-paretic knee power, and paretic step ratio.

RESULTS

Specific to those who reached MCID in SSWS (e.g. "responders"), significant improvements in SSWS, FCWS, 6-MWT, paretic knee power, and non-paretic knee power was realized. Paretic knee power and non-paretic knee power significantly improved in those who did not achieve MCID for gait speed (e.g. "non-responders").

CONCLUSION

The potential for POWER training to enhance general locomotor function was confirmed. Baseline paretic knee strength/power may be an important factor in how an individual responds to this style of training. The lack of change within the non-responders emphasizes the contribution of factors other than lower extremity muscle power improvement to locomotor dysfunction.

Strength Training for Skeletal Muscle Endurance after Stroke

BACKGROUND AND PURPOSE

Initial studies support the use of strength training (ST) as a safe and effective intervention after stroke. Our previous work shows that relatively aggressive, higher intensity ST translates into large effect sizes for paretic and non-paretic leg muscle volume, myostatin expression, and maximum strength post-stroke. An unanswered question pertains to how our unique ST model for stroke impacts skeletal muscle endurance (SME). Thus, we now report on ST-induced adaptation in the ability to sustain isotonic muscle contraction.

METHODS

Following screening and baseline testing, hemiparetic stroke participants were randomized to either ST or an attention-matched stretch control group (SC). Those in the ST group trained each leg individually to muscle failure (20 repetition sets, 3× per week for 3 months) on each of three pneumatic resistance machines (leg press, leg extension, and leg curl). Our primary outcome measure was SME, quantified as the number of submaximal weight leg press repetitions possible at a specified cadence. The secondary measures included one-repetition maximum strength, 6-minute walk distance (6MWD), 10-meter walk speeds, and peak aerobic capacity (VO₂ peak).

RESULTS

ST participants (N = 14) had significantly greater SME gains compared with SC participants (N = 16) in both the paretic (178% versus 12%, P < .01) and non-paretic legs (161% versus 12%, P < .01). These gains were accompanied by group differences for 6MWD (P < .05) and VO₂ peak (P < .05).

CONCLUSION

Our ST regimen had a large impact on the capacity to sustain submaximal muscle contraction, a metric that may carry more practical significance for stroke than the often reported measures of maximum strength.

180° turn while walking: characterization and comparisons between subjects with and without stroke

[Purpose] Limitations in performing the 180°-turning increase the risk of falls and disabilities in stroke patients. The aim of this study was to characterize and compare the 180°-turning between people with and without stroke, considering the direction towards which they turned. [Subjects and Methods] Fourteen subjects with stroke and 14 matched healthy controls performed the 180°-turning twice while walking: towards the self-selected, and the opposite directions. The turning performances were recorded using three video cameras. The videos were randomly analyzed by a single examiner, who characterized the turning, while considering the time required to complete the task, the number of steps, balance, and turning type. Friedman Tests and ANOVA (2 × 2) were used to compare the groups and turning direction factors (turning towards the self-selected versus opposite sides, and towards the paretic/non-dominant versus non-paretic/dominant sides). [Results] No interaction between the groups and turning directions, and no significant differences between the turning directions were found. However, significant differences were found between the groups for all variables used to characterize the turning performance, except for the type of turning. [Conclusion] Stroke subjects demonstrated poor performance on the 180°-turning, regardless of the turning direction. Duration, number of steps, and balance loss indicated difficulties in turn performance.

Sarcopenia and Physical Function in Middle-Aged and Older Stroke Survivors

OBJECTIVES

To determine the prevalence of sarcopenia in stroke survivors using different methodologies, and compare a subset of the stroke group to age-, sex-, and body mass index (BMI)-matched nonstroke control counterparts.

DESIGN

Cohort study.

SETTING

A Veterans Affairs medical center and a university hospital.

PARTICIPANTS

Mild to moderately disabled participants >6 months after onset of stroke aged 40 to 84 years (N=190, 61% men, 57% African American; mean BMI ± SEM, 29±1kg/m²).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Dual-energy x-ray absorptiometry scans to assess appendicular lean mass (ALM). Rates of sarcopenia were determined using 4 established methods: (1) ALM/height² (ALM/ht²); (2) European Working Group on Sarcopenia in Older Persons; (3) International Working Group on Sarcopenia; and (4) ALM/BMI.

RESULTS

Sarcopenia prevalence in our stroke cohort ranged between 14% and 18%. The stroke survivor subset (n=38) matched one-for-one with control counterparts for race, sex, age ±4 years and BMI ±2.5kg/m² had higher prevalence rates compared with their nonstroke counterparts (13.2% vs 5.3%, P<.0001). ALM/ht² was related to 6-minute walking speed (r=.28, P<.01) and peak oxygen consumption (L/min: r=.58, P<.0001) for the stroke group.

CONCLUSIONS

Stroke survivors show an elevated prevalence of sarcopenia when considering age, sex, and race compared with nonstroke individuals.

Aerobic treadmill plus Bobath walking training improves walking in subacute stroke: a randomized controlled trial

Objective: To evaluate the immediate and long-term effects of aerobic treadmill plus Bobath walking training in subacute stroke survivors compared with Bobath walking training alone.

Design: Randomized controlled trial.

Setting: Rehabilitation unit.

Subjects: Fifty patients, first-time supratentorial stroke, stroke interval less than six weeks, Barthel Index (0 / 100) from 50 to 80, able to walk a minimum distance of 12 m with either intermittent help or stand-by while walking, cardiovascular stable, minimum 50 W in the bicycle ergometry, randomly allocated to two groups, A and B.

Interventions: Group A 30 min of treadmill training, harness secured and minimally supported according to patients' needs, and 30 min of physiotherapy, every workday for six weeks, speed and inclination of the treadmill were adjusted to achieve a heart rate of HR: (Hrmax / HRrest)*0.6 / HRrest; in group B 60 min of daily physiotherapy for six weeks.

Main outcome measures: Primary outcome variables were the absolute improvement of walking velocity (m/s) and capacity (m), secondary were gross motor function including walking ability (score out of 13) and walking quality (score out of 41), blindly assessed before and after the intervention, and at follow-up three months later.

Results: Patients tolerated the aerobic training well with no side-effects, significantly greater improvement of walking velocity and capacity both at study end (p / 0.001 versus p / 0.002) and at follow-up (p < 0.001 versus p<0.001) in the experimental group. Between weeks 0 and 6, the experimental group improved walking speed and capacity by a mean of.31 m/s and 91 m, the control group by a mean of 0.16 m/s and 56 m. Between weeks 0 and 18, the experimental group improved walking speed and capacity by a mean of 0.36 m/s and 111 m, the control group by a mean of 0.15 m/s and 57 m. Gross motor function and walking quality did not differ at any time.

Conclusions: Aerobic treadmill plus Bobath walking training in moderately affected stroke patients was better than Bobath walking training alone with respect to the improvement of walking velocity and capacity. The treatment approach is recommended in patients meeting the inclusion criteria. A multicentre trial should follow to strengthen the evidence.

Jump training is feasible for nearly ambulatory patients after stroke

Objective: To evaluate the feasibility of jump training for nearly ambulatory patients after stroke.

Design: Case series.

Setting: A rehabilitation centre for adult people with neurological disorders.

Subjects: Six subacute, nearly ambulatory patients with hemiparesis due to stroke.

Interventions: A modified form of jump training performed over a period of six weeks.

Measures: Impairments: We used the Motricity Index to measure strength, the Fugl-Meyer subtest passive joint motion/pain for range of motion and pain and the modified Tardieu Scale to measure spasticity at baseline and after six weeks. Activity level: To assess walking ability we used the Functional Ambulation Category, to measure walking quality we used 10-m gait velocity, stride length and Rivermead Visual Gait Index and to assess walking capacity we used the six-minute walk test.

Results: No severe adverse events were observed during the study period. Motricity Index sum score of the affected leg increased from 38±11 points (mean±SD) to 56±15 points; P = 0.028. Modified Tardieu Scale and Fugl-Meyer subtest passive joint motion/pain remained unchanged over time (P=1.0; P=0.157, respectively). All patients were able to walk at the end of training (median Functional Ambulation Category grade five, P=0.023). Gait quality improved as shown in increased gait velocity (from 0.3±0.1 to 1.1±0.5 m/s; P = 0.028), improved stride length (from 0.3±0.1 to 0.6±0.2 m; P = 0.028) and improved Rivermead Visual Gait Index score (from 38.7±5.6 points to 24.8±7.0 points; P = 0.027). All patient increased gait capacity (from 97±33 m to 289±134 m; P = 0.028).

Conclusion: Jump exercises are feasible for selected subacute stroke patients with hemiparesis.

Treadmill Training with Partial Body Weight Support in Hemiparetic Patients—Further Research Needed

Treadmill training with partial body weight support is a promising new therapy in gait rehabilitation of hemiparetic subjects. As a task-specific training it enables the repetitive practice of complex gait cycles at a very early stage. Initially two or even three therapists assist the movement so that the subjects train gait not only repeti tively but also in a correct manner. Several controlled studies have documented its effectiveness in gait rehabilitation of acute and chronic stroke patients and have shown that hemiparetic patients walked in a more dynamic, symmetric, and less spastic fash ion on the treadmill with body weight support as compared with ground-level walk ing. Nevertheless, to meet the criteria of evidence-based medicine, further compara tive studies will be needed, supplemented by research in basic neurophysiology to explain its effects and technology to alleviate the strenuous effort of therapists during the training. Possible solutions are functional electrical stimulation (FES) in combi nation with treadmill training and a mechanized gait trainer.

Timing, Intensity, and Duration of Rehabilitation for Hip Fracture and Stroke: Report of a Workshop at the National Center for Medical Rehabilitation Research

This article summarizes the proceedings of an NIH workshop on timing, intensity, and duration of rehabilitation for acute stroke and hip fracture. Participants concentrated on methodological issues facing investigators and suggested priorities for future research in this area.

Coordination of Hemiparetic Locomotion after Stroke Rehabilitation

Objectives. Determine whether a rehabilitation program targeting functional motor recovery of persons with poststroke hemiparesis improved motor coordination. Methods. A subgroup of 20 persons with poststroke hemiparesis (n = 11 in intervention and n =9incontrol group) was investigated from within a larger randomized controlled single-blind clinical trial of 100 patients. Motor coordination was measured using a pedaling task, and subjects in the intervention group pedaled during an intensive broad-based home exercise program that targeted flexibility, strength, balance, and endurance. Coordination variables based on paretic leg pedal forces and EMG of 4 thigh muscles were measured while pedaling pre- and postintervention. Results. Despite extensive pedaling practice, up to 30 half-hour sessions that were progressively more intense, there was no effect (P > 0.05) of the intervention on percent of total work done by the paretic leg, quantitative measures of EMG, or pedaling speed. However, walking speed was improved and pedaling and walking faster were associated after the intervention. Conclusions. There is no evidence of improved locomotor coordination postintervention. The increased walking and pedaling speed was likely achieved by a more proficient use of the same impaired pattern without EMG timing changes, likely because of increased strength and endurance postintervention. A more task-specific intervention may be required to improve coordination, consistent with principles of use-dependent plasticity.

An Overview of Treadmill Locomotor Training with Partial Body Weight Support: A Neurophysiologically Sound Approach Whose Time Has Come for Randomized Clinical Trials

Much of the rehabilitation team's effort during inpatient and outpatient therapy for disabling neurologic diseases aims to restore the ability to walk with as little human assistance as possible. Although the use of treadmill (TM) training with partial body weight support has a strong underpinning from basic and clinical neuroscience stud ies and small clinical trials, the technique still lacks the reproducible results that make for an evidence-based practice. Therapists will have to learn how to employ body weight-supported treadmill training (BWSTT) so that they optimize the segmental sensory inputs that best facilitate spinal and supraspinal locomotor networks. Ran domized clinical trials must be undertaken using scientific expertmental designs that measure the impact of BSWTT on the lives of hemiparetic and paraparetic people. Outcomes specific to a locomotor intervention might include functional independence for walking and for mobility-related self-care and community activities, walking speed, endurance for walking distances, and the perceptions of subjects about health-related quality of life. Features of training and trial design are discussed in relation to reported basic and clinical research.

Validating accelerometry as a measure of physical activity and energy expenditure in chronic stroke

BACKGROUND

Accelerometers can objectively measure steps taken per day in individuals without gait deficits, but accelerometers also have the ability to estimate frequency, intensity, and duration of physical activity. However, thresholds to distinguish varying levels of activity intensity using the Actical brand accelerometer are standardized only for the general population and may underestimate intensity in stroke.

OBJECTIVE

To derive Actical activity count thresholds specific to stroke disability for use in more accurately gauging time spent at differing activity levels.

METHODS

Men (n = 18) and women (n = 10) with chronic hemiparetic gait (4 ± 2 years latency, 43% Caucasian, 56% African-American, ages of 47-83 years, BMI 19-48 kg/m²) participated in the study. Actical accelerometers were placed on the non-paretic hip to obtain accelerometry counts during eight activities of varying intensity: (1) watching TV; (2) seated stretching; (3) standing stretching; (4) floor sweeping; (5) stepping in place; (6) over-ground walking; (7) lower speed treadmill walking (1.0 mph at 4% incline); and (8) higher speed treadmill walking (2.0 mph at 4% incline). Simultaneous portable monitoring (Cosmed K4b2) enabled quantification of energy cost for each activity in metabolic equivalents (METs, or oxygen consumption in multiples of resting level). Measurements were obtained for 10 min of standard rest and 5 min during each of the eight activities.

RESULTS

Regression analysis yielded the following new stroke-specific Actical minimum thresholds: 125 counts per minute (cpm) for sedentary/light activity, 667 cpm for light/moderate activity, and 1546 cpm for moderate/vigorous activity.

CONCLUSION

Our revised cut points better reflect activity levels after stroke and suggest significantly lower thresholds relative to those observed for the general population of healthy individuals. We conclude that the standard, commonly applied Actical thresholds are inappropriate for this unique population.

Respiratory function and functional capacity in chronic stroke patients 1

Abstract Introduction: Cerebrovascular accident (CVA) or stroke results in weakness of the trunk muscles and physical unfitness. Objectives: To evaluate respiratory changes caused by stroke and correlate them with the functional capacity of chronic stroke patients who were treated at the Clinical Center of Physical Therapy of the Pontifical Catholic University of Minas Gerais, Betim. Methods: Fifteen patients were recruited for assessment of respiratory function and functional capacity. We measured maximum inspiratory pressure (MIP), maximal expiratory pressure (MEP), peak expiratory flow (PEF), vital capacity (VC), and functional capacity using the six-minute walk test (6MWT). Test results were compared with reference values using an unpaired Student's t-test or the Mann-Whitney test. Respiratory variables were correlated with the distance walked in the 6MWT using Spearman's correlation test. Results: The sample had a mean age of 58.2 ± 13.4 years, and most patients had a diagnosis of ischemic stroke and left hemiparesis. The following values were obtained: MIP (47.7 ± 22.2 cmH2O); MEP (47.5 ± 20.3 cmH2O); PEF (351.3 ± 90.8 L/min); VC (3.0 ± 0.91 L); and 6MWT (222.4 ± 101.6 m). The MIP, MEP, PEF, and 6MWT values measured in this study were statistically significantly lower (p < 0.001) than the reference values. There was no statistically significant correlation between the distance walked in the 6 MWT and respiratory variables (p > 0.005). Conclusion: Our results suggest that, despite the decrease in respiratory muscle strength, PEF, and VC, these variables did not correlate with the functional capacity of the chronic stroke patients assessed in this study.

Gait post-stroke: Pathophysiology and rehabilitation strategies

We reviewed neural control and biomechanical description of gait in both non-disabled and post-stroke subjects. In addition, we reviewed most of the gait rehabilitation strategies currently in use or in development and observed their principles in relation to recent pathophysiology of post-stroke gait. In both non-disabled and post-stroke subjects, motor control is organized on a task-oriented basis using a common set of a few muscle modules to simultaneously achieve body support, balance control, and forward progression during gait. Hemiparesis following stroke is due to disruption of descending neural pathways, usually with no direct lesion of the brainstem and cerebellar structures involved in motor automatic processes. Post-stroke, improvements of motor activities including standing and locomotion are variable but are typically characterized by a common postural behaviour which involves the unaffected side more for body support and balance control, likely in response to initial muscle weakness of the affected side. Various rehabilitation strategies are regularly used or in development, targeting muscle activity, postural and gait tasks, using more or less high-technology equipment. Reduced walking speed often improves with time and with various rehabilitation strategies, but asymmetric postural behaviour during standing and walking is often reinforced, maintained, or only transitorily decreased. This asymmetric compensatory postural behaviour appears to be robust, driven by support and balance tasks maintaining the predominant use of the unaffected side over the initially impaired affected side. Based on these elements, stroke rehabilitation including affected muscle strengthening and often stretching would first need to correct the postural asymmetric pattern by exploiting postural automatic processes in various particular motor tasks secondarily beneficial to gait.

Physiological Effects of Exercise on Stroke Survivors

PURPOSE

This study investigated the physiological responses of stroke survivors to a 16-week program of moderate aerobic and anaerobic exercise.

METHOD

Forty participants who were a minimum of 6 months post stroke underwent physiological testing over the course of 2 days that included a maximal VO(2) stress test, a Biodex strength assessment, and a blood lipid panel. The participants were then randomly assigned to two groups, an aerobic training only (ATO) group and an aerobic and strength training (A&ST) group. Both groups were then required to exercise aerobically for 20 minutes for 3 days a week at a moderate intensity for 16 weeks. Only the A&ST group was required to do a series of eight strength-training activities as part of their exercise protocol. Once the 16-week protocol was completed, all tests were repeated. These results were compared to the pretest data.

RESULTS

Statistically significant changes in VO(2max) were noted in the A&ST group, while positive but not significant changes were noted in the ATO group. Both groups saw significant increases in knee flexion but not in knee extension. The A&ST group showed significant increases in both shoulder flexion and extension, while the ATO group only had significant increases in shoulder extension.

CONCLUSION

We concluded that aerobic exercise produced positive metabolic changes in both groups, but only the A&ST group had statistically significant changes. Both groups demonstrated significant changes in functional strength, but the A&ST group experienced larger increases, likely due to the strength component of their training protocol.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Energy flow analysis of the lower extremity during gait in persons with chronic stroke

BACKGROUND

A decline in walking capacity and high energy cost can limit mobility following stroke. Mechanical energy exchange between lower limb and trunk segments can reflect gait inefficiencies, but reveals little about active energy flow between adjacent segments through muscle actions. This study evaluated mechanical energy expenditures (MEEs) during walking in stroke and healthy groups to understand movement control and explore the impact of walking speed on mechanical energy exchanges.

METHODS

Thirteen adults with hemiparesis and six healthy controls walked at self-selected speed. Power curves for each lower limb joint were segmented into concentric and eccentric sources of muscle power and transfer/no-transfer modes to calculate MEEs during stance.

FINDINGS

MEEs were lower in the stroke group on the affected side compared to the less affected side and compared to controls. Specifically, the affected plantarflexors transferred less energy distally via concentric action in late stance compared to the less affected side. However, the stroke group generated greater energy at the ankle in the absence of transfer compared to controls. Less concentrically transferred energy through midstance and absorbed in late stance was evident by the knee extensors bilaterally in stroke. At the hip, the total energy (no transfer) was reduced on the affected side. Classifying stroke subjects by walking speed (<.6m/s, >.6m/s) revealed disruptions in harnessing energy through motion and transfer energy across segments in the slower group.

INTERPRETATION

The limited ability of those with stroke to exploit intersegmental energy transfer to optimize efficiency may limit endurance and functional independence.

Immediate effects of low-intensity laser (808 nm) on fatigue and strength of spastic muscle

The cerebrovascular accident (CVA), high-impact disease II, affects the basic functions of the limbs, leading to changes of sensory, language, and motor functions. The search for resources that minimize the damage caused by this disease grows every day. The clinical use of low-intensity laser therapy (LILT) has provided major breakthroughs in the treatment of muscular disorders and prevention of muscle fatigue. Thus, the objective of the present study is to analyze the answers and immediate adaptations of the rectus femoris and vastus medialis of spastic hemiparetic patients, facing the increase in peak torque and triggering muscle fatigue, after application of LILT. Double-blind clinical trials were conducted with 15 volunteers post-CVA with spasticity, of both genders, between 40 and 80 years old. To this end, the volunteers went through three consecutive stages of rating (control, placebo, and laser). All performed tests of isometric contraction on the patient's hemiparetic side. Significant differences were observed with regard to the increase in muscle performance (p = 0.0043) and the reduction in blood lactate concentration (p < 0.0001) of the post-LILT muscles. The LILT (diode laser, l100 mW 808 nm, 4.77 J/cm(2)/point, 40 s/AP) can be employed during and after spastic muscle-strengthening exercises, contributing to the improvement of motor function of the patient. After application of LILT, we found increased torque as well as decreased in lactate level in patients with spasticity.

Post-Stroke Consultation Service: A Nurse-Managed Model for Care Delivery

In 1989, a multidisciplinary consultation service devoted to providing primary care and rehabilitative care services to stroke survivors in the home was developed and tested at the University of Pennsylvania. This nurse-managed service, Post-Stroke Consultation Service, used the expertise of a nurse practitioner, geriatrician, physiatrist, physical therapists, home health care nurses, specialty care providers, families, and stroke survivors to develop and implement a plan of care that optimized health and function and would be sustainable over time. The service and its impact are described.

Ambulatory Activity Intensity Profiles, Fitness, and Fatigue in Chronic Stroke

PURPOSE

The purpose of this study was to describe household and community ambulatory activity profiles and their relationship to fatigue and cardiovascular fitness in a sample of men and women with chronic hemiparetic stroke.

METHOD

We quantified community-based ambulatory activity profiles in terms of step counts and intensity, along with cardiovascular fitness and fatigue severity, in a convenience sample of 79 men and women with chronic hemiparetic stroke.

RESULTS

As captured by daily step activity monitoring, participants demonstrated extremely low step counts (1389 +/- 797 steps/day), and almost no step activity at high intensity (78 +/- 168 steps/day at a rate of >or=30 steps/ minute). Mean high intensity activity constituted less than 3 minutes/day. The mean VO2 peak was 13.02 +/- 4.26 mL/kg/min, consistent with profound aerobic deconditioning. Total, low, and high intensity ambulatory activity were associated with VO2 peak. Mean fatigue severity was 3.28 +/- 1.36 on a scale of 7.00, with 42% of the sample reporting severe fatigue. There were no statistically significant correlations between fatigue severity and ambulatory activity or fitness measures.

CONCLUSION

Our results show that step activity intensity is strongly associated with cardiovascular fitness, lending credence to the hypothesis that rehabilitation interventions that build aerobic conditioning can influence daily activity. The challenge is to appreciate the features of ambulatory behavior after stroke and to use this information to integrate both exercise interventions and behavioral components into the successful translation of structured activities into home and community routines.

Does the speed of the treadmill influence the training effect in people learning to walk after stroke? A double-blind randomized controlled trial

OBJECTIVE

To compare the effectiveness of high-speed treadmill training and progressive treadmill training for stroke patients.

DESIGN

A double-blind, randomized controlled trial.

SETTING

Inpatient rehabilitation hospital.

PARTICIPANTS

A total of 61 ambulatory stroke patients.

INTERVENTIONS

Patients in both groups underwent treadmill training for 30 minutes with conventional intervention. The progressive training group (n = 31) was trained to walk on a treadmill with a stepwise increase of speed over the treatment period. The high-speed training group (n = 30) trained to begin at 1.2-1.3 m/s, which is faster than the mean speed of stroke patients. All participants underwent 20 training sessions for five weeks.

MAIN MEASURES

Timed up-and-go test, 10-m walk test, 6-minute walk test, and both step lengths and cadence.

RESULTS

There were significant improvements in the results of the timed up-and-go test (-1.96 vs. -5.02 seconds), 10-m walk test (0.30 vs. 0.47 m/s), 6-minute walk test (38.35 vs. 64.40 m), and in the step length of the affected side (0.14 vs. 0.19 m) and the unaffected side (0.10 vs. 0.12 m) in the high-speed training group compared with those in the progressive training group (p < 0.05). Step width was not changed in either group (p > 0.05).

CONCLUSION

These results suggest that high-speed training is an effective method for improving the walking ability of stroke patients.

Feasibility of virtual reality augmented cycling for health promotion of people poststroke

BACKGROUND AND PURPOSE

A virtual reality (VR) augmented cycling kit (VRACK) was developed to address motor control and fitness deficits of individuals with chronic stroke. In this article, we report on the safety, feasibility, and efficacy of using the VR augmented cycling kit to improve cardiorespiratory (CR) fitness of individuals in the chronic phase poststroke.

METHODS

Four individuals with chronic stroke (47-65 years old and ≥3 years poststroke), with residual lower extremity impairments (Fugl-Meyer 24-26/34), who were limited community ambulators (gait speed range 0.56-1.1 m/s) participated in this study. Safety was defined as the absence of adverse events. Feasibility was measured using attendance, total exercise time, and "involvement" measured with the presence questionnaire (PQ). Efficacy of CR fitness was evaluated using a submaximal bicycle ergometer test before and after an 8-week training program.

RESULTS

The intervention was safe and feasible with participants having 1 adverse event, 100% adherence, achieving between 90 and 125 minutes of cycling each week, and a mean PQ score of 39 (SD 3.3). There was a statistically significant (13%; P = 0.035) improvement in peak VO(2), with a range of 6% to 24.5%.

DISCUSSION AND CONCLUSION

For these individuals, poststroke, VR augmented cycling, using their heart rate to set their avatar's speed, fostered training of sufficient duration and intensity to promote CR fitness. In addition, there was a transfer of training from the bicycle to walking endurance. VR augmented cycling may be an addition to the therapist's tools for concurrent training of mobility and health promotion of individuals poststroke.

Feasibility and potential efficacy of high-intensity stepping training in variable contexts in subacute and chronic stroke

BACKGROUND

Previous data suggest that the amount and aerobic intensity of stepping training may improve walking poststroke. Recent animal and human studies suggest that training in challenging and variable contexts can also improve locomotor function. Such practice may elicit substantial stepping errors, although alterations in locomotor strategies to correct these errors could lead to improved walking ability.

OBJECTIVE

This unblinded pilot study was designed to evaluate the feasibility and preliminary efficacy of providing stepping practice in variable, challenging contexts (tasks and environments) at high aerobic intensities in participants >6 months and 1-6 months post-stroke.

METHODS

A total of 25 participants (gait speeds <0.9 m/s with no more than moderate assistance) participated in ≤40 training sessions (duration of 1 hour) within 10 weeks. Stepping training in variable, challenging contexts was performed at 70% to 80% heart rate reserve, with feasibility measures of total steps/session, ability to achieve targeted intensities, patient tolerance, dropouts, and adverse events. Gait speed, symmetry, and 6-minute walk were measured every 4 to 5 weeks or 20 sessions, with a 3-month follow-up (F/U).

RESULTS

In all, 22 participants completed ≥4 training weeks, averaging 2887 ± 780 steps/session over 36 ± 5.8 sessions. Self-selected (0.38 ± 0.27 to 0.66 ± 0.35 m/s) and fastest speed (0.51 ± 0.40 to 0.99 ± 0.58 m/s), paretic single-limb stance (20% ± 5.9% to 25% ± 6.4%), and 6-minute walk (141 ± 99 to 260 ± 146 m) improved significantly at posttraining.

CONCLUSIONS

This preliminary study suggests that stepping training at high aerobic intensities in variable contexts was tolerated by participants poststroke, with significant locomotor improvements. Future studies should delineate the relative contributions of amount, intensity, and variability of stepping training to maximize outcomes.