Aerobic exercise interventions for promoting cardiovascular health and mobility after stroke: a systematic review with Bayesian network meta-analysis

OBJECTIVE

To determine the superiority of aerobic exercise (AE) interventions on key outcomes of stroke recovery, including cardiorespiratory fitness (V̇O2peak, primary outcome), systolic blood pressure (SBP) and mobility (6 min Walk Test (6MWT) distance and 10 m Usual Gait Speed) after stroke.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, CINAHL, CENTRAL, SPORTDiscus, PsycINFO and AMED Allied and Complementary Medicine were searched from inception to February 2023.

ELIGIBILITY CRITERIA

Randomised controlled trials were included that compared the effects of any AE interventions (low-intensity, moderate-intensity, high-intensity continuous training (HICT), high-intensity interval training (HIIT)) to no exercise, usual care or other AE interventions in individuals poststroke.

ANALYSES

Systematic review with Bayesian network meta-analysis (NMA) methodology was employed. Surface under the cumulative ranking curve (SUCRA) values were used to rank interventions. The Grading of Recommendations, Assessment, Development and Evaluation minimally contextualised framework for NMA was followed.

RESULTS

There were 28 studies (n=1298) included in the NMA for V̇O2peak, 11 (n=648) for SBP, 28 (n=1494) for 6MWT and 18 (n=775) for the 10 m Usual Gait Speed. The greatest effect on V̇O2peak, 6MWT and 10 m Usual Gait Speed was observed after HIIT and HICT. No differences between interventions were found for SBP. SUCRA values identified HIIT as the superior AE intervention for all outcomes of interest. HIIT was the most effective intervention for improving V̇O2peak (2.9 mL/kg/min (95% credible interval 0.8 to 5.0) moderate certainty) compared with usual care.

CONCLUSION

This NMA suggests that higher-intensity AE is superior to traditional low-intensity to moderate-intensity AE for improving outcomes after stroke.

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.

Is early initiated cardiorespiratory fitness training within a model of stroke-integrated cardiac rehabilitation safe and feasible?

OBJECTIVE

To investigate the safety and feasibility of an early initiated stroke-integrated Cardiac Rehabilitation program.

METHODS

People with acute first or recurrent ischaemic stroke, admitted to Epworth HealthCare were screened for eligibility and invited to participate. In addition to usual care neurorehabilitation, participants performed 1) cardiorespiratory fitness training 3-days/week during inpatient rehabilitation (Phase 1), and/or 2) 2-days/week centre-based cardiorespiratory fitness training plus education and 1-day/week home-based cardiorespiratory fitness training for 6-weeks during outpatient rehabilitation (Phase 2). Safety was determined by the number of adverse and serious adverse events. Feasibility was determined by participant recruitment, retention, and attendance rates, adherence to exercise recommendations, and participant satisfaction.

RESULTS

There were no study-related adverse or serious adverse events. Of 117 eligible stroke admissions, 62 (53%) were recruited, while 10 (16.1%) participants withdrew. Participants attended 189 of 201 (94%) scheduled cardiorespiratory fitness training sessions in Phase 1 and 341/381 (89.5%) scheduled sessions in Phase 2. Only 220/381 (58%) scheduled education sessions were attended. The minimum recommended cardiorespiratory fitness training intensity (40% heart rate reserve) and duration (20 minutes) was achieved by 57% and 55% of participants respectively during Phase 1, and 60% and 92% respectively during Phase 2. All respondents strongly agreed (69%) or agreed (31%) they would recommend the stroke-integrated Cardiac Rehabilitation program to other people with stroke.

CONCLUSION

Cardiorespiratory fitness training in line with multiple clinical practice guidelines included within a model of stroke-integrated Cardiac Rehabilitation appears to be safe and feasible in the early subacute phase post-stroke.

Comparative efficacy of different exercise methods to improve cardiopulmonary function in stroke patients: a network meta-analysis of randomized controlled trials

Background

Although some studies have shown that exercise has a good effect on improving the cardiopulmonary function of stroke patients, it still needs to be determined which exercise method does this more effectively. We, therefore, aimed to evaluate the effectiveness of different exercise methods in improving cardiovascular function in stroke patients through a network meta-analysis (NMA), providing a basis to select the best treatment plan for stroke patients.

Methods

We systematically searched CNKI, WanFang, VIP, CBM, PubMed, Embase, Web of Science, and The Cochrane Library databases from establishment to 30 April 2023. Randomized controlled trials (RCTS) on exercise improving cardiopulmonary function in stroke patients were included, and we screened the included articles and extracted the relevant data. RevMan (version 5.4) and Stata (version 17.0) were used for data analysis.

Results

We included 35 RCTs and a total of 2,008 subjects. Intervention measures included high-intensity interval training (HIIT), aerobic training (AT), resistance training (RT), combined aerobic and resistance exercise (CE), and conventional therapy (CT). In the network meta-analysis, the surface under the cumulative ranking area (SUCRA) ranking result indicated that HIIT improved peak oxygen uptake (VO2peak) and 6 mins walking distance (6MWD) optimally, with rankings of HIIT (100.0%) > CE (70.5%) > AT (50.2%) > RT (27.7%) > CT (1.6%), and HIIT (90.9%) > RT (60.6%) > AT (48.9%) > RT (48.1%) > CT (1.5%), respectively. The SUCRA ranking result showed that CE improved systolic blood pressure (SBP) and diastolic blood pressure (DBP) optimally, with rankings of CE (82.1%) > HIIT (49.8%) > AT (35.3%) > CT (32.8%), and CE (86.7%) > AT (45.0%) > HIIT (39.5%) > CT (28.8%), respectively.

Conclusion

We showed that exercise can effectively improve the cardiopulmonary function of stroke patients. HIIT was the most effective in improving VO2peak and 6MWD in stroke patients. CE was the most effective in improving SBP and DBP in stroke patients. However, due to the limitations of existing clinical studies and evidence, larger sample size, multi-center, and high-quality RCTs are needed to verify the above conclusions in the future.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier [CRD42023436773].

Moderate to Vigorous Intensity Locomotor Training After Stroke: A Systematic Review and Meta-analysis of Mean Effects and Response Variability

BACKGROUND AND PURPOSE

This meta-analysis quantified mean effects of moderate to vigorous intensity locomotor training (LT mv ) on walking outcomes in subacute and chronic stroke, and the magnitude of variability in LT mv response.

METHODS

Databases were searched for randomized trials comparing LT mv with no intervention, nongait intervention, or low-intensity gait training. Comfortable gait speed (CGS), fastest gait speed (FGS), 6-minute walk test (6MWT), walking activity (steps per day), and adverse effect/event (AE) data were extracted. Pooled estimates were calculated for mean changes, AE relative risks, and the standard deviation of response (SD response ) to LT mv versus control groups, stratified by study chronicity where possible.

RESULTS

There were 19 eligible studies (total N = 1096): 14 in chronic stroke (N = 839) and 5 in subacute stroke (N = 257). Compared with control interventions, LT mv yielded significantly greater increases in CGS (chronic, +0.06 m/s [95% confidence interval (CI), 0.01-0.10]; subacute, +0.16 [0.12-0.19]; subacute vs chronic, P = 0.03), FGS (chronic, +0.07 m/s [0.02-0.13]; subacute, +0.21 [0.01, 0.41]; P = 0.04), and 6MWT (chronic, +33 m [24-42]; subacute, +51 [26-77]; P = 0.054) but not steps/day (+260 [-1159 to 1679]). There were no treatment-related serious AEs among 398 LT mv participants in 14 AE-reporting studies. SD response estimates indicated substantial response variability: CGS, 0.11 m/s [0.00-0.15]; FGS, 0.14 m/s [-0.00 to 0.20]; and 6MWT, 41 m [27-51].

DISCUSSION AND CONCLUSIONS

LT mv improves mean walking capacity outcomes in subacute and chronic stroke and does not appear to have high risk of serious harm. Response magnitude varies within and between chronicity subgroups, and few studies have tested effects on daily walking activity or non-serious AEs.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A452 ).

A rehabilitative approach beyond the acute stroke event: a scoping review about functional recovery perspectives in the chronic hemiplegic patient

Background

Stroke is a main cause of disability worldwide and its neuro-rehabilitative management is not limited to the acute phase but requires continuity in the rehabilitation approach especially in the chronic phase. The aim of this scoping review was to highlight the different treatment opportunities available in neurorehabilitation, effective for patients with chronic stroke sequelae, not only in terms of maintaining motor function but also improving it.

Methods

The literature search was conducted using the following databases: MEDLINE (PubMed), PEDro, Scopus, Web of Science (WOS), Cochrane from 2012 to February 2023. We selected Randomized Clinical Trials in English dealing with neurorehabilitation strategies in chronic hemiplegic patients after stroke focusing on motor function, muscular strength, gait, postural balance, spasticity, and quality of life.

Results

According to the inclusion criteria, 47 articles were selected for our review. All of them were analyzed following the primary outcome and the rehabilitation technique used. Despite the different protocols used within the same technique and despite the chronicity of the disease, all studies report an improvement after the rehabilitation treatment of motor function and quality of life.

Conclusion

The literature analyzed invites us to reflect respect to neurorehabilitation approach to the patient with chronic stroke sequelae often considered to have as its objective the maintenance of the present motor function and contain disability: instead, the review reports how, even in chronicity, the patient always reports margins of statistically and clinically significant improvement. The chronic stroke rehabilitation over 6 months has been proved effective in obtaining recovery in different settings.

Feasibility of challenging treadmill speed-dependent gait and perturbation-induced balance training in chronic stroke patients with low ambulation ability: a randomized controlled trial

Background

Treadmill training shows advantages in the specificity, amount, and intensity of gait and balance practice for the rehabilitation of stroke patients.

Objective

To investigate the feasibility and effectiveness of challenging treadmill speed-dependent gait and perturbation-induced balance training in chronic stroke patients with low ambulation ability.

Methods

For this randomized controlled trial (Chinese Clinical Trials.gov registration number ChiCTR-IOR-16009536) with blinded testers, we recruited 33 ambulatory stroke participants with restricted community ambulation capacity and randomly assigned them into two groups: the experimental group with 2 week treadmill speed-dependent gait training combined with 2 week treadmill perturbation-induced balance training (EXP) or the control group with traditional gait and balance training (CON). Various variables were recorded during EXP training, including the rating of perceived exertion, heart rate, causes of pauses, treadmill speed, and perturbation intensity. Outcome measures were examined before training and at 2 and 4 weeks after training. They included gait velocity during five-meter walk test at comfortable and fast speed and reactive balance ability in the compensatory stepping test as primary outcome measures, as well as dynamic balance ability (timed up-and-go test and 5 times sit-to-stand test) and balance confidence as secondary outcome measures.

Results

All participants completed the study. The treadmill speed and perturbation intensity significantly increased across training sessions in the EXP group, and no adverse effects occurred. The normal and fast gait velocities showed significant time and group interaction effects. They significantly increased after 2 and 4 weeks of training in the EXP group (p < 0.05) but not in the CON group (p > 0.05). Likewise, dynamic balance ability measured using the timed up-and-go test at a fast speed significantly improved after 2 and 4 weeks of training in the EXP group (p < 0.05) but not in the CON group (p > 0.05), although without a significant time and group interaction effect. Surprisingly, the reactive balance ability did not show improvement after treatment in the EXP group (p > 0.05).

Conclusion

Challenging treadmill speed-dependent gait and treadmill perturbation-induced balance training is feasible and effective to improve ambulation function in chronic stroke patients with low ambulation ability.

Comparative efficacy of gait training for balance outcomes in patients with stroke: A systematic review and network meta-analysis

Background

Growing evidence suggests that gait training can improve stroke patients’ balance outcomes. However, it remains unclear which type of gait training is more effective in improving certain types of balance outcomes in patients with stroke. Thus, this network meta-analysis (NMA) included six types of gait training (treadmill, body-weight-supported treadmill, virtual reality gait training, robotic-assisted gait training, overground walking training, and conventional gait training) and four types of balance outcomes (static steady-state balance, dynamic steady-state balance, proactive balance, and balance test batteries), aiming to compare the efficacy of different gait training on specific types of balance outcomes in stroke patients and determine the most effective gait training.

Method

We searched PubMed, Embase, Medline, Web of Science, and Cochrane Library databases from inception until 25 April 2022. Randomized controlled trials (RCTs) of gait training for the treatment of balance outcomes after stroke were included. RoB2 was used to assess the risk of bias in the included studies. Frequentist random-effects network meta-analysis (NMA) was used to evaluate the effect of gait training on four categories of balance outcomes.

Result

A total of 61 RCTs from 2,551 citations, encompassing 2,328 stroke patients, were included in this study. Pooled results showed that body-weight-support treadmill (SMD = 0.30, 95% CI [0.01, 0.58]) and treadmill (SMD = 0.25, 95% CI [0.00, 0.49]) could improve the dynamic steady-state balance. Virtual reality gait training (SMD = 0.41, 95% CI [0.10, 0.71]) and body-weight-supported treadmill (SMD = 0.41, 95% CI [0.02, 0.80]) demonstrated better effects in improving balance test batteries. However, none of included gait training showed a significant effect on static steady-state balance and proactive balance.

Conclusion

Gait training is an effective treatment for improving stroke patients’ dynamic steady-state balance and balance test batteries. However, gait training had no significant effect on static steady-state balance and proactive balance. To achieve maximum efficacy, clinicians should consider this evidence when recommending rehabilitation training to stroke patients. Considering body-weight-supported treadmill is not common for chronic stroke patients in clinical practice, the treadmill is recommended for those who want to improve dynamic steady-state balance, and virtual reality gait training is recommended for those who want to improve balance test batteries.

Limitation

Missing evidence in relation to some types of gait training is supposed to be taken into consideration. Moreover, we fail to assess reactive balance in this NMA since few included trials reported this outcome.

Systematic Review Registration

PROSPERO, identifier CRD42022349965.

Effects of 2-Year-Long Maintenance Training and Detraining on 558 Subacute Ischemic Stroke Patients' Clinical-Motor Symptoms

PURPOSE

This study aimed to determine the effects of a 2-yr-long maintenance training (MT) exergaming and detraining (DT) on clinical-motor symptoms in subacute ischemic patients with stroke (PwST). The hypothesis was that MT motor rehabilitation program would further increase the effects of the initial rehabilitation.

METHODS

After high-intensity and high-frequency exergaming twice or once a day, 5 times per week for 5 wk (EX2: 50 sessions; EX1: 25 sessions, results reported previously), 558 PwST were randomized to EX2-MT, EX2-DT, EX1-MT, and EX1-DT. MT exergaming consisted of once a day, 3 times per week for 2 yr, and DT did not train. Outcomes were measured at 6, 12, 18, and 24 months. The data were analyzed using longitudinal linear mixed-effects models and general linear hypotheses testing.

RESULTS

Modified Rankin Score (primary outcome), body mass, Mini-Mental State Examination score, Beck Depression Inventory, measures of quality of life, Berg Balance Scale, 6-min walk test, and four measures of center of pressure path tended to retain the initial rehabilitation-induced gains in the MT patients in selected outcomes (especially walking capacity). The scores tended to mildly worsen after DT, partially supporting the hypothesis.

CONCLUSIONS

MT successfully maintained, but only in selected variables did it further increase the initial exergaming rehabilitation-induced robust improvements. DT modestly reduced the initial exergaming rehabilitation-induced improvements. MT programs might be needed after initial stroke rehabilitation to reduce subsequent losses of quality of life and further improve clinical-motor symptoms.

Walking on inclines alters the gait characteristics in patients with acute stroke

BACKGROUND

Stroke leads to severe difficulties in daily activities, even when performing a simple task, such as walking from one point to another. The first apparent compensatory strategy in stroke survivors during walking is to slow down the walking speed. Slowing down the walking speed directly reduces the step length and cadence and further increases the stance phase, double, and support time. These alterations are to develop a compensatory strategy; however, this strategy generally leads to joint injuries and increases the potential risks of falls.

RESEARCH QUESTION

A review strongly suggests that walking on the inclines may enhance this compensatory strategy. Therefore, this study attempted to extend the current knowledge to understand the fundamental gait control in patients with acute stroke during walking on inclines.

RESULTS

These results showed that (1) compared to healthy control, patients with acute stroke demonstrated different gait controls during walking on inclines, (2) the gait performance was enhanced when stroke patients were instructed on different inclines, and (3) the asymmetric gait pattern was reduced by walking on inclines.

SIGNIFICANCE

This study concluded that walking on inclines enhances gait performance (greater spatial but smaller temporal gait characteristics) and reduces spatial gait asymmetry.

Exercise prescription, intervention, dissemination, and implementation following transient ischemic attack or stroke: advancing the field through interdisciplinary science

Research has demonstrated that both exercise, and a reduction in cardiovascular disease (CVD) risk factors (i.e., high blood sugar, blood lipids, and blood pressure), following a stroke or transient ischemic attack (TIA) are beneficial for reducing risk of recurrent stroke or TIA and for improving overall quality of life. Despite this evidence, many stroke and TIA survivors remain inactive and sedentary and present with multiple CVD risk factors. The purpose of this commentary is to highlight gaps in the current literature in regard to exercise and behavior interventions for the stroke and TIA populations, present ideas for intervention design, and discuss the dissemination and implementation of research findings. The future research ideas presented in this commentary are based on current research findings, as well as the professional experience of the article authors. Professional experience spans occupational therapy in neurorehabilitation, clinical exercise physiology in rehabilitation, creation and implementation of stroke rehabilitation clinics, stroke and TIA research, and behavioral and implementation science.

Feasibility of performing a multi-arm clinical trial examining the novel combination of repetitive transcranial magnetic stimulation and aerobic exercise for post-stroke depression

BACKGROUND

Post-stroke depression (PSD) occurs in approximately one-third of chronic stroke survivors. Although pharmacotherapy reduces depressive symptoms, side effects are common and stroke survivors have increased likelihood of multimorbidity and subsequent polypharmacy. Thus, alternative non-pharmacological treatments are needed. Combining two non-pharmacological anti-depressant treatments, aerobic exercise (AEx) and repetitive transcranial magnetic stimulation (rTMS), has been demonstrated to be feasible and well-tolerated in chronic stroke survivors.

OBJECTIVES

The purpose of this trial was to determine the feasibility of conducting a multi-arm combinatorial trial of rTMS and AEx and to provide an estimate of effect size of rTMS+AEx on PSD symptoms.

METHODS

Twenty-four participants were allocated to one of four treatment arms AEx, rTMS, rTMS+AEx, or non-depressed Control receiving AEx. All participants received a total of 24 treatment sessions. Participant adherence was the primary outcome measure for feasibility and within group effect sizes in Patient Health Questionnaire-9 (PHQ-9) score was the primary outcome for preliminary efficacy.

RESULTS

Mean adherence rates to the exercise intervention for AEx, rTMS+AEx, and Control subjects were 83%, 98%, and 95%, respectively. Mean adherence rates for rTMS and rTMS+AEx subjects were 97% and 99%, respectively. The rTMS and rTMS+AEx treatment groups demonstrated clinically significant reductions of 10.5 and 6.2 points in PHQ-9 scores, respectively.

CONCLUSION

Performing a multi-arm combinatorial trial examining the effect of rTMS+AEx on PSD appears feasible. All treatment arms demonstrated strong adherence to their respective interventions and were well received. rTMS and the combination of AEx with rTMS may be alternative treatments for PSD.

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.

An impairment-specific hip exoskeleton assistance for gait training in subjects with acquired brain injury: a feasibility study

This study was designed to investigate the feasibility and the potential effects on walking performance of a short gait training with a novel impairment-specific hip assistance (iHA) through a bilateral active pelvis orthosis (APO) in patients with acquired brain injury (ABI). Fourteen subjects capable of independent gait and exhibiting mild-to-moderate gait deficits, due to an ABI, were enrolled. Subjects presenting deficit in hip flexion and/or extension were included and divided into two groups based on the presence (group A, n = 6) or absence (group B, n = 8) of knee hyperextension during stance phase of walking. Two iHA-based profiles were developed for the groups. The protocol included two overground gait training sessions using APO, and two evaluation sessions, pre and post training. Primary outcomes were pre vs. post-training walking distance and steady-state speed in the 6-min walking test. Secondary outcomes were self-selected speed, joint kinematics and kinetics, gait symmetry and forward propulsion, assessed through 3D gait analysis. Following the training, study participants significantly increased the walked distance and average steady-state speed in the 6-min walking tests, both when walking with and without the APO. The increased walked distance surpassed the minimal clinically important difference for groups A and B, (respectively, 42 and 57 m > 34 m). In group A, five out of six subjects had decreased knee hyperextension at the post-training session (on average the peak of the knee extension angle was reduced by 36%). Knee flexion during swing phase increased, by 16% and 31%, for A and B groups respectively. Two-day gait training with APO providing iHA was effective and safe in improving walking performance and knee kinematics in ABI survivors. These preliminary findings suggest that this strategy may be viable for subject-specific post-ABI gait rehabilitation.

"Magic" Number of Treadmill Sessions Needed to Achieve Meaningful Change in Gait Speed After Stroke: A Systematic Review

ABSTRACT

The purpose of this systematic review was to determine the number of treadmill training sessions needed to make a meaningful change in gait speed for chronic stroke survivors. Relevant databases were searched up through February 2020. Articles were included if they fit the following criteria: stroke onset more than 5 mos, intention to treat with traditional treadmill training, and gait speed included as an outcome. Change in gait speed after intervention was used to classify treadmill groups as responders (at least 0.1 m/sec change) or nonresponders (less than 0.1 m/sec change). Seventeen articles met our criteria, resulting in a total of 19 intervention groups. Ten groups were classified as responders and completed a mean of 30.5 sessions within 6 wks, whereas nonresponders completed 20.4 sessions within 10 wks, indicating that at least 30 treadmill sessions (preferably in a period of 10 wks and at least 40 mins per session) is necessary to reach a meaningful change in gait speed. Although these trends were noted between the responder and nonresponder groups, no firm conclusions can be drawn regarding the "magic" number of sessions chronic stroke survivors should perform given the low correlation between number of sessions and change in gait speed.

Stroke volume and cardiac output during 6 minute-walk tests are strong predictors of maximal oxygen uptake in people after stroke

Background and objectives

The 6-minute walk test (6MWT) is a field test commonly used to predict peak oxygen consumption (VO2peak) in people after stroke. Inclusion of cardiodynamic variables measured by impedance cardiography (ICG) during a 6MWT has been shown to improve prediction of VO2peak in healthy adults but these data have not been considered in people after stroke. This study investigates whether the prediction of VO2peak can be improved by the inclusion of cardiovascular indices derived by impedance cardiography (ICG) during the 6MWT in people after stroke.

Methods

This was a cross-sectional study. Patients diagnosed with stroke underwent in random order, a maximal cardiopulmonary exercise test (CPET) and 6MWT in separate dates. Heart rate (HR), stroke volume (SV) and cardiac output (CO) were measured by ICG during all tests. Oxygen consumption was recorded by a metabolic cart during the CPET. Recorded data were subjected to multiple regression analyses to generate VO2peak prediction equations.

Results

Fifty-nine patients, mean age 50.0±11.7 years were included in the analysis. The mean distance covered in the 6MWT (6MWD) was 294±13 m, VO2peak was 19.2±3.2 ml/min/kg. Mean peak HR, SV and CO recorded during 6MWT were 109±6 bpm, 86.3±8.8 ml, 9.4±1.2 L/min and during CPET were 135±14 bpm, 86.6±9 ml, 11.7±2 L/min respectively. The prediction equation with inclusion of cardiodynamic variables: 16.855 + (-0.060 x age) + (0.196 x BMI) + (0.01 x 6MWD) + (-0.416 x SV6MWT) + (3.587 x CO 6MWT) has a higher squared multiple correlation (R2) and a lower standard error of estimate (SEE) and SEE% compared to the equation using 6MWD as the only predictor.

Conclusion

Inclusion of SV and CO measured during the 6MWT in stroke patients further improved the VO2peak prediction power compared to using 6MWD as a lone predictor.

Integration of persuasive elements into exergames: Application in the development of a novel gait rehabilitation system for children with musculoskeletal conditions

The main contribution of this paper is the application of the Persuasive System Design (PSD) model for the analysis and development of exergame systems to stimulate pediatric patients to adhere to short-term gait rehabilitation. It resulted in a novel therapy consisting of a video gaming and virtual reality (VG/VR) biofeedback system for treadmill gait rehabilitation, including a method for progressing the rehabilitation settings. During gait rehabilitation (GR) sessions, therapy settings need to be adjusted by physiotherapists, based on their clinical experience, to address the deficiencies of individuals while maximizing their motor functioning and maintaining their motivation. The system integrates persuasive elements, adjusted when physiotherapists progress the therapeutic settings, such as the treadmill speed, auditory feedback, and game challenges. We followed a scenario-based design method to develop the system, which comprised an observational study of conventional GR sessions and evaluations with 6 and 9 rehabilitation specialists who provided feedback about the system design. They perceived that the proposed method was valuable for physiotherapists to adapt the rehabilitation based on the children's performance. Also, they remarked that the system's visual and auditory stimulus would help engage the children in the therapy.

The Effect of Inclines on Joint Angles in Stroke Survivors During Treadmill Walking

Stroke severely affects the quality of life, specifically in walking independently. Thus, it is crucial to understand the impaired gait pattern. This gait pattern has been widely investigated when walking on a level treadmill. However, knowledge about the gait pattern when walking on inclines is scarce. Therefore, this study attempted to fulfill this knowledge gap. In this study, 15 stroke survivors and 15 age/height/weight healthy controls were recruited. The participants were instructed to walk on three different inclines: 0°, 3°, and 6°. The participants were required to walk on each incline for 2 min and needed to complete each incline two times. The dependent variables were the peak values for ankle/knee/hip joint angles and the respective variability of these peak values. The results showed that an increment of the incline significantly increased the peak of the hip flexion and the peak of the knee flexion but did not affect the peak values of the ankle joints in the paretic leg in these stroke survivors. In comparison with the healthy controls, lower hip extension, lower hip flexion, lower knee flexion, and lower ankle plantar flexion were observed in stroke survivors. A clinical application of this work might assist the physical therapists in building an effective treadmill training protocol.

High Level Mobility Training in Ambulatory Patients with Acquired Non-Progressive Central Neurological Injury: a Feasibility Study

The purpose of this study was to test the feasibility and safety of High-Level Mobility (HLM) training on adults with Acquired Brain Injury (ABI). Our hypotheses were that HLM training would be feasible and safe. This study was a pilot randomized control trial with a Simple Skill Group (SSG) and a Complex Skill Group (CSG). Both groups received 12 sessions over 8 weeks and completed 4 testing sessions over 16 weeks. The SSG focused on locomotion, while CSG focused on the acquisition of running. Feasibility was assessed in terms of process, resources, management, and scientific metrics, including safety. Among the 41 participants meeting inclusion criteria, 28 consented (CSG, n = 13, SSG, n = 15), 20 completed the assigned protocol and 8 withdrew (CSG n = 4, SSG n = 4). Adherence rate to assigned protocol was 100%. There were two Adverse Events (AEs), 1 over 142 SSG sessions and 1 over 120 CSG sessions. The AE Odd Ratio (OR) (CSG:SSG) was 1.18 (95% CI: 0.07, 19.15). The data support our hypotheses that HLM training is feasible and safe on ambulatory adults with ABI.

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.

Effect of cycling exercise on motor excitability and gait abnormalities in stroke patients

Background

The concepts of brain excitability are still re-wiring in response to changes in environment. Ambulation is often limited in stroke patients.

Objective

To determine the effect of cycling exercise on motor excitability and consequences on spatiotemporal gait parameters in stroke patients.

Methods

Forty male ischemic stroke patients were included; their age ranged from 45 to 60 years. The patients were assigned into two equal groups: control group (GI) and study group (GII). The GI is treated by a design physical therapy program in the form of task-oriented progressive resistance exercise for lower limb muscles, and the GII is treated by the same program in addition to cycling exercise for 30 min. Treatment was conducted three times per week for 10 weeks. The excitability over motor area (Cz) was assessed by the quantitative electroencephalogram (QEEG). The spatiotemporal gait parameters were assessed by the Biodex Gait Trainer 2TM.

Results

There was a significant increase of speed, step cycle, and step length of the affected side (P < 0.05) and a non-significant difference of step length of the non-affected side in the study group compared with that of the control group (P > 0.05). There was a significant increase of excitability over motor area (Cz) in the study group compared with that of the control group (P < 0.05).

Conclusion

Cycling exercise has a positive effect on excitability over motor area of lower limbs and can improve gait parameters in stroke patients.

The Effects of Sit-to-Stand Training Combined with Real-Time Visual Feedback on Strength, Balance, Gait Ability, and Quality of Life in Patients with Stroke: A Randomized Controlled Trial

This study aimed to investigate the effects of lower limbs muscles' strength, balance, walking, and quality of life through sit-to-stand training combined with real-time visual feedback (RVF-STS group) in patients with stroke and to compare the effects of classic sit-to-stand training (C-STS group). Thirty patients with stroke were randomly divided into two groups. The RVF-STS group received sit-to-stand training combined with real-time visual feedback using a Wii Balance Board (n = 15), and the C-STS group received classic sit-to-stand training (n = 15). All participants received training for 20 min once a day, 5 days a week for 6 weeks, and both groups underwent general physical therapy for 30 min before training. Before and after the training, the muscle strength of the hip flexor, abductor, and knee extensor were measured, and the Wii Balance Board was used to perform the center of pressure test and Berg Balance Scale to evaluate static and dynamic balance. Additionally, the 10 m walking test and the Timed Up and Go test were performed to evaluate gait function. The Stroke-Specific Quality of Life was used to measure the quality of life. The results showed that the lower extremity muscle strength, balance ability, walking ability, and quality of life of the RVF-STS group significantly improved in comparison of the pre- and post-differences (p < 0.05), and it also showed significant differences between groups (p < 0.05). This study showed that sit-to-stand training combined with real-time visual feedback was effective at improving the muscle strength of the lower extremities, balance, gait, and quality of life in patients with stroke. Therefore, repeating sit-to-stand training combined with real-time visual feedback could be used as an effective treatment method for patients with stroke.

Factors associated with balance impairments amongst stroke survivors in northern Benin: A cross-sectional study

Background

Balance impairment is the predominant risk factor for falls in stroke survivors. A fear of falling after stroke can contribute to sedentary lifestyles, increased disability and risk of recurrence, leading to poor quality of life.

Objective

To determine the frequency and factors associated with balance impairments amongst stroke survivors at the University Hospital of Parakou.

Method

This cross-sectional study included adult stroke survivors. Stroke survivors after discharge were enrolled at the University Hospital of Parakou between 01 January 2020 and 30 September 2020. Balance impairments were measured by using the Berg Balance Scale (BBS), the Timed Up and Go (TUG) and the Get Up and Go (GUG) tests.

Results

A total of 54 stroke survivors were included, with a mean age of 58.37 ± 12.42 years and a male predominance of 68.52%. The mean BBS score was 36.87 ± 14.34 with a minimum and a maximum of 10 and 56, respectively. Thirteen (24.07%) had balance impairments (BBS score ≤ 20), 34 (62.96%) had a TUG score ≥ 14 s (abnormal), 9 (16.67%) presented a moderate risk of falling and 6 (11.11%) presented high risk of fall with the GUG test. Post-stroke duration (odds ratio [OR] = 0.04; 95% CI: 0.04–0.30; p < 0.01), severity of disability (OR = 8.33; 95% CI: 1.03–67.14; p = 0.03) and the number of physiotherapy sessions (OR = 0.18; 95% CI: 0.03–0.93; p = 0.02) were significantly associated with balance impairments.

Conclusion

Our results showed that almost one quarter of stroke survivors after discharge at the University Hospital of Parakou had balance impairments. Post-stroke duration, severity of disability and the number of physiotherapy sessions were significantly associated with balance impairments.

Clinical implications

[AQ1] Balance should be regularly assessed in people post-stroke. Further studies should document the content of rehabilitation and any rehabilitative efforts to improve balance in people post-stroke in Benin.

Development and Results of an Implementation Plan for High-Intensity Gait Training

BACKGROUND AND PURPOSE

High-intensity gait training is recommended in stroke rehabilitation to improve gait speed, walking distance, and balance. However, identifying effective and efficient implementation methods is a challenge for rehabilitation providers. This article describes the development of an implementation plan, presents findings of each implementation phase, and identifies the project's impact on clinicians and the health system.

METHODS

Two inpatient rehabilitation facilities, including 9 physical therapists, collaborated with a knowledge translation center to implement this program. We developed an implementation plan using the Knowledge-to-Action Framework and utilized the Consolidated Framework for Implementation Research to identify barriers and select implementation strategies. Using mix-methods research, including surveys and informal discussions, we evaluated current practice, barriers, outcomes, and the sustainability of high-intensity gait training in practice.

RESULTS

A multicomponent implementation plan that targeted barriers was developed. Before implementation, clinicians reported providing several balance, strength training, and gait interventions to improve walking. Barriers to using high-intensity gait training included knowledge, beliefs, adaptability of high-intensity gait training, resources, culture, and others. Twenty-six implementation strategies were selected to target the barriers. Surveys and informal discussions identified significant changes in perceived practice, adoption of high-intensity gait training, and positive impacts on the health system. The 2-year follow-up survey indicated that the new practice was sustained.

DISCUSSION AND CONCLUSIONS

Using a multicomponent implementation plan that targeted barriers, we successfully implemented high-intensity gait training in clinical practice. Contributors to successful implementation may include the implementation methods, usual care interventions, and clinicians' readiness for this change.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A352.).

The acute effects of aerobic exercise on sensorimotor adaptation in chronic stroke

Background:

Sensorimotor adaptation, or the capacity to adapt movement to changes in the moving body or environment, is a form of motor learning that is important for functional independence (e.g., regaining stability after slips or trips). Aerobic exercise can acutely improve many forms of motor learning in healthy adults. It is not known, however, whether acute aerobic exercise has similar positive effects on sensorimotor adaptation in stroke survivors as it does in healthy individuals.

Objective:

The aim of this study was to determine whether acute aerobic exercise promotes sensorimotor adaptation in people post stroke.

Methods:

A single-blinded crossover study. Participants attended two separate sessions, completing an aerobic exercise intervention in one session and a resting control condition in the other session. Sensorimotor adaptation was assessed before and after each session, as was brain derived neurotrophic factor. Twenty participants with chronic stroke completed treadmill exercise at moderate to high intensity for 30 minutes.

Results:

Acute aerobic exercise in chronic stroke survivors significantly increased sensorimotor adaptation from pre to post treadmill intervention. The 30-minute treadmill intervention resulted in an averaged 2.99 ng/ml increase in BDNF levels (BDNF pre-treadmill = 22.31 + /–2.85 ng/ml, post-treadmill was = 25.31 + /–2.46 pg/ml; t(16) = 2.146, p = 0.048, cohen’s d = 0.521, moderate effect size).

Conclusions:

These results indicate a potential role for aerobic exercise to promote the recovery of sensorimotor function in chronic stroke survivors.

A decision making algorithm for rehabilitation after stroke: A guide to choose an appropriate and safe treadmill training

BACKGROUND

Walking independently after a stroke can be difficult or impossible, and walking reeducation is vital. But the approach used is often arbitrary, relying on the devices available and subjective evaluations by the doctor/physiotherapist. Objective decision making tools could be useful.

OBJECTIVES

To develop a decision making algorithm able to select for post-stroke patients, based on their motor skills, an appropriate mode of treadmill training (TT), including type of physiotherapist support/supervision required and safety conditions necessary.

METHODS

We retrospectively analyzed data from 97 post-stroke inpatients admitted to a NeuroRehabilitation unit. Patients attended TT with body weight support (BWSTT group) or without support (FreeTT group), depending on clinical judgment. Patients' sociodemographic and clinical characteristics, including the Cumulative Illness Rating Scale (CIRS) plus measures of walking ability (Functional Ambulation Classification [FAC], total Functional Independence Measure [FIM] and Tinetti Performance-Oriented Mobility Assessment [Tinetti]) and fall risk profile (Morse and Stratify) were retrieved from institutional database.

RESULTS

No significant differences emerged between the two groups regarding sociodemographic and clinical characteristics. Regarding walking ability, FAC, total FIM and its Motor component and the Tinetti scale differed significantly between groups (for all, p < 0.001). FAC and Tinetti scores were used to elaborate a decision making algorithm classifying patients into 4 risk/safety (RS) classes. As expected, a strong association (Pearson chi-squared, p < 0.0001) was found between RS classes and the initial BWSTT/FreeTT classification.

CONCLUSION

This decision making algorithm provides an objective tool to direct post-stroke patients, on admission to the rehabilitation facility, to the most appropriate form of TT.

Restoration of motor function after CNS damage: is there a potential beyond spontaneous recovery?

What determines the effectiveness of neurorehabilitation approaches on the outcome of function in stroke or spinal cord injured subjects? Many studies claim that an improvement of function is based on the intensity of training, while some actual studies indicate no additional gain in function by a more intensive training after a stroke. Inherent factors seem to determine outcome, such as damage of specific tracts in stroke and level of lesion in spinal cord injured subjects, while the improvement of function achieved by an intensive training is small in relation to the spontaneous recovery. It is argued that an individual capacity of recovery exists depending on such factors. This capacity can be exploited by a repetitive execution of functional movements (supported as far as required), irrespective of the intensity and technology applied. Elderly subjects have difficulties to translate the recovery of motor deficit into function. Alternative, non-training approaches to restore motor function, such as epidural or deep brain stimulation as well as CNS repair are still in an early clinical or in a translational stage.

Effects of High-Intensity Interval Training After Stroke (The HIIT Stroke Study) on Physical and Cognitive Function: A Multicenter Randomized Controlled Trial

OBJECTIVE

To assess the effects of high-intensity interval training (HIIT) on physical, mental, and cognitive functioning after stroke.

DESIGN

The HIIT Stroke Study was a single-blind, multicenter, parallel-group randomized controlled trial.

SETTING

Specialized rehabilitation units at 3 Norwegian hospitals.

PARTICIPANTS

Adult stroke survivors (N=70) 3 months to 5 years after a first-ever stroke. Mean age was 57.6±9.2 years and 58.7±9.2 years in the intervention and control groups, respectively.

INTERVENTIONS

Participants were randomized to standard care in combination with 4×4 minutes of treadmill HIIT at 85%-95% of peak heart rate or standard care only.

OUTCOMES

Outcomes were measured using physical, mental, and cognitive tests and the FIM and Stroke Impact Scale. Linear mixed models were used to analyze differences between groups at posttest and 12-month follow-up.

RESULTS

The intervention group showed a significant treatment effect (95% confidence interval [CI]) from baseline to posttest on a 6-minute walk test of 28.3 (CI, 2.80-53.77) meters (P=.030); Berg Balance Scale 1.27 (CI, 0.17-2.28) points (P=.025); and Trail Making Test Part B (TMT-B; -24.16 [CI, -46.35 to -1.98] s, P=.033). The intervention group showed significantly greater improvement on TMT-B at the 12-month follow-up (25.44 [CI, -49.01 to -1.87] s, P=.035). The control group showed significantly greater improvement in total Functional Independence Measure score with a treatment effect of -2.37 (CI, -4.30 to -0.44) points (P=.016) at 12-month follow-up. No significant differences were identified between groups on other outcomes at any time point.

CONCLUSIONS

HIIT combined with standard care improved walking distance, balance, and executive function immediately after the intervention compared with standard care only. However, only TMT-B remained significant at the 12-month follow-up.

Task-Oriented Circuit Training as an Alternative to Ergometer-Type Aerobic Exercise Training after Stroke

Moderate-intensity aerobic exercise training is an important treatment strategy to enhance functional recovery and decrease cardiometabolic risk factors after stroke. However, stroke related impairments limit access to ergometer-type exercise. The aims of the current study were (1) to evaluate whether our task-oriented circuit training protocol (intermittent functional training; IFT) could be used to sustain moderate-intensity aerobic workloads over a 10-week intervention period, and (2) to investigate its preliminary effects on cardiorespiratory fitness and metabolic profiles compared to constant-load ergometer-type exercise (CET). Forty chronic hemiparetic stroke survivors were randomized to receive 30 sessions of IFT or CET over ten weeks. Similar proportions of participants were randomized to IFT (7/19) and CET (9/18) sustained workloads associated with moderate-intensity aerobic exercise over the study period (p = 0.515). However, CET was associated with more substantial changes in maximal oxygen uptake (MD = 2.79 mL min⁻¹ kg⁻¹ CI: 0.84 to 4.74) compared to IFT (MD = 0.62 mL min⁻¹ kg⁻¹ CI: −0.38 to 1.62). Pre to post changes in C-reactive protein (−0.9 mg/L; p =0.017), short-term glycemia (+14.7 µmol/L; p = 0.026), and resting whole-body carbohydrate oxidation (+24.2 mg min⁻¹; p = 0.046) were observed when considering both groups together. Accordingly, IFT can replicate the aerobic intensities sustained during traditional ergometer-type exercise training. More work is needed to evaluate the dose–response effects of such task-oriented circuit training protocols on secondary prevention targets across the continuum of stroke recovery.

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

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

Impact of Intensive Gait Training With and Without Electromechanical Assistance in the Chronic Phase After Stroke-A Multi-Arm Randomized Controlled Trial With a 6 and 12 Months Follow Up

Introduction: Movement related impairments and limitations in walking are common long-term after stroke. This multi-arm randomized controlled trial explored the impact of training with an electromechanically assisted gait training (EAGT) system, i.e., the Hybrid Assistive Limb^® (HAL), when integrated with conventional rehabilitation focused on gait and mobility.

Material and Methods: Participants, aged 18–70 years with lower extremity paresis but able to walk with manual support or supervision 1–10 years after stroke, were randomized to (A) HAL-training on a treadmill, combined with conventional rehabilitation interventions (HAL-group), or (B) conventional rehabilitation interventions only (Conventional group), 3 days/week for 6 weeks, or (C) no intervention (Control group). Participants in the Control group were interviewed weekly regarding their scheduled training. Primary outcome was endurance in walking quantified by the 6 Minute Walk Test (6MWT). A rater blinded to treatment allocation performed assessments pre- and post-intervention and at follow-ups at 6 and 12 months. Baseline assessment included the National Institute of Health Stroke Scale (NIHSS) and the Modified Ranking Scale (MRS). Secondary outcomes included the Fugl Meyer Assessment- Lower Extremity, 10 Meter Walk Test, Berg Balance Scale (BBS), Barthel Index (BI) and perceived mobility with the Stroke Impact Scale.

Results: A total of 48 participants completed the intervention period. The HAL-group walked twice as far as the Conventional group during the intervention. Post-intervention, both groups exhibited improved 6 MWT results, while the Control group had declined. A significant improvement was only found in the Conventional group and when compared to the Control group (Tukey HSD p = 0.022), and not between the HAL group and Conventional group (Tukey HSD p = 0.258) or the HAL- group and the Control group (Tukey HSD p = 0.447). There was also a significant decline in the Conventional group from post-intervention to 6 months follow up (p = 0.043). The best fitting model to predict outcome included initial balance (BBS), followed by stroke severity (NIHSS), and dependence in activity and participation (BI and MRS).

Conclusion: Intensive conventional gait training induced significant improvements long-term after stroke while integrating treadmill based EAGT had no additional value in this study sample. The results may support cost effective evidence-based interventions for gait training long-term after stroke and further development of EAGT.

Trial registration: Published on clinicaltrials.gov (NCT02545088) August 24, 2015.

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).

Effectiveness of walking training on balance, motor functions, activity, participation and quality of life in people with chronic stroke: a systematic review with meta-analysis and meta-regression of recent randomized controlled trials

PURPOSE

To review and quantify the effects of walking training for the improvement of various aspects of physical function of people with chronic stroke.

METHODS

We conducted a systematic search and meta-analysis of randomized controlled trials (RCTs) of chronic stroke rehabilitation interventions published from 2008 to 2020 in English or French. Of the 6476-screened articles collated from four databases, 15 RCTs were included and analyzed. We performed a meta-regression with the total training time as dependent variable in order to have a better understanding of how did the training dosage affect the effect sizes.

RESULTS

Treadmill walking training was more effective on balance and motor functions (standardized mean difference (SMD)=0.70[0.02, 1.37], p = 0.04) and 0.56[0.15, 0.96], p = 0.007 respectively). Overground walking training improved significantly walking endurance (SMD = 0.38[0.16, 0.59], p < 0.001), walking speed (MD = 0.12[0.05, 0.18], p < 0.001), participation (SMD = 0.35[0.02, 0.68], p = 0.04) and quality of life (SMD = 0.46[0.12, 0.80], p = 0.008). Aquatic training improved balance (SMD = 2.41[1.20, 3.62], p < 0.001). The Meta-regression analysis did not show significant effect of total training time on the effect sizes.

CONCLUSION

Treadmill and overground walking protocols consisting of ≥30 min sessions conducted at least 3 days per week for about 8 weeks are beneficial for improving motor impairments, activity limitations, participation, and quality of life in people with chronic stroke.Implications for rehabilitationTreadmill walking training is effective for improving balance and motor functions.Overground walking training improved significantly walking endurance, walking speed, participation and quality of life.Treadmill and overground walking protocols consisting of ≥30 min sessions conducted at least 3 days per week for about 8 weeks are beneficial for improving motor impairments, activity limitations, participation, and quality of life in patient with chronic stroke.

Longer-term health and social care strategies for stroke survivors and their carers: the LoTS2Care research programme including cluster feasibility RCT

Background

It is reported that the longer-term outcomes for stroke survivors are poor, with a range of unmet needs identified.

Objectives

The aims were to develop and test a longer-term stroke care strategy focused on improving the quality of life of stroke survivors and their carers by addressing unmet needs, and maintenance and enhancement of participation (i.e. involvement in life situations).

Design

Five overlapping workstreams were undertaken – (1) refinement of content by semistructured interviews with stroke survivors and their carers and by a review of the literature to inform content and delivery of the care strategy; (2) exploration of service models by national survey and focus groups with purposely selected services; (3) intervention development by interaction with a reference group of stroke survivors, carers, and health and social care professionals; (4) refinement and pilot implementation of the developed intervention in three stroke services (case studies); and (5) a cluster randomised controlled feasibility trial in 10 stroke services across England and Wales.

Setting

The intervention development work and feasibility trial were in stroke services (inclusive of primary, secondary, community and social care provision) across England and Wales.

Participants

Participants were stroke survivors resident in the community and their carers, and health and social care professionals in the included stroke services.

Data sources

Interviews with 28 stroke survivors and their carers at least 9 months post stroke ascertained their needs and the barriers to and facilitators of addressing those needs. Additional literature reviews identified 23 needs. No evidence-based interventions to address these needs were reported; self-management was highlighted as a possible delivery mechanism. In workstream 2, a national survey revealed that the most common model of stroke service provision was care up to 12 months post stroke, reported by 46 (40%) services. Thirty-five (30%) services provided care up to 6 months post stroke and 35 (30%) provided care beyond 12 months, thus identifying 6 months post stroke as an appropriate delivery point for a new intervention. Through focus groups in a range of services, stroke survivors’ perceived unmet needs and the barriers to and enablers of service provision were identified.

Intervention

Using information obtained in workstreams 1 and 2 and working closely with a stakeholder reference group, we developed an intervention based on the unmet needs prioritised by stroke survivors and their carers (workstream 3). In workstream 4, action groups (clinicians, stroke survivors and researchers) were established in three stroke services that led implementation in their service and contributed to the iterative refinement of the intervention, associated training programme and implementation materials. The intervention (called New Start) was delivered at 6 months post stroke. Key components were problem-solving self-management with survivors and carers, help with obtaining usable information, and helping survivors and their carers build sustainable, flexible support networks.

Results

A cluster randomised feasibility trial (workstream 5) was successfully implemented in 10 stroke services across England and Wales, with associated process and health economic evaluations. Five services were randomised to provide New Start, while five continued with usual care; 269 participants were recruited. Progression criteria – in terms of our pre-determined (red, amber, green) criteria for progress to a full trial: target stroke survivor recruitment rates were achieved, on average, across sites (24.1 per site over 6 months, green); 216 (80.3%) registered stroke survivors returned follow-up questionnaires at 9 months (84.1% in the intervention arm and 75.8% in the usual care arm, green); according to data reported by sites, overall, 95.2% of registered stroke survivors were offered at least one session of the intervention (green); all five intervention sites had at least two facilitators deemed competent, delivered the New Start intervention and provided it to stroke survivors (green). However, at some sites, there were concerns regarding the number of stroke survivors being offered, accepting and receiving the intervention. Only small differences in outcomes and costs were observed between the New Start and usual care groups, and considerable uncertainty around the cost-effectiveness remains.

Conclusions

We report a complex programme of work that has described the longer-term needs of stroke survivors and highlighted evidence and service gaps. Working closely with stroke survivors, an intervention was developed that has been refined in three services and feasibility tested in a cluster randomised controlled trial. Further refinement of the target population and optimisation of the intervention materials is required prior to a full randomised controlled trial evaluation.

Future work

Optimisation of the intervention, and clearer specification of recipients, are required prior to a full trial evaluation.

Trial registration

Current Controlled Trials ISRCTN38920246.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

Lessons Learned: The Difficulties of Incorporating Intensity Principles Into Inpatient Stroke Rehabilitation

Objective

The objective of this study was to determine the feasibility of a rehabilitation approach focusing on cardiovascular, strength, and gait training intensity in the inpatient rehabilitation setting after a new onset of stroke. We additionally aimed to determine the efficacy of this intensity-based program on rehabilitation outcomes compared with usual care.

Design

Participants were pseudo-randomized to an intensity-based program focusing on gait, cardiovascular, and strength training or to usual care. Outcomes included FIM, 10-meter walk, 2-minute walk, timed Up and Go test, 5-time sit-to-stand test, and Tinetti balance assessment.

Intervention

The intervention consisted of 6 20-minute sessions per week dedicated to intensity of activity: 2 each for walking, cardiovascular training, and strength training.

Participants

Patients (N=49) with new onset stroke admitted to inpatient rehabilitation over the course of 1 year.

Setting

Four inpatient rehabilitation facilities with comprehensive neurologic rehabilitation teams.

Results

Thirty-five individuals (16 intervention, 19 controls) completed all testing. Subject compliance to the intensity intervention demonstrated completion of approximately half the prescribed sessions. All outcomes improved significantly from admission to discharge, and a significant interaction between treatment group and time was observed for the 2-minute walk and the Tinetti balance assessment. The 2-minute walk, Tinetti balance assessment, 10-meter walk, and FIM demonstrated between-group effect sizes greater than 0.60 in favor of the intervention group.

Conclusions

The intensity-based protocol was safe, and several measures demonstrated efficacy when compared with usual care. Results may have been limited by poor program compliance, showing a need to identify and ameliorate obstacles to integration of comprehensive intensity-based programs addressing endurance, strength, and gait training. Applying physiological principles of exercise to acute stroke rehabilitation demonstrates great promise for improving independent physical function.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

LIMITATIONS

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

SUMMARY

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

DISCLAIMER

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

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.

Effects of detraining on cardiorespiratory fitness of individuals with chronic stroke

BACKGROUND

Aerobic training can improve cardiorespiratory fitness in individuals after stroke. However, the effects of short-term and long-term detraining are not well known.

OBJECTIVE

To determine the effects of short-term (1-month) and long-term (6-month) detraining on cardiorespiratory fitness (VO_2peak) of individuals after stroke, who participated in aerobic training.

METHODS

A cohort study was developed. Twenty adults (57 ± 11 years old) with stroke were included. After completing an outpatient aerobic training, participants were divided into gain group (VO_2peak increase >1.3 ml.kg^-1.min^-1 from before to immediately after the training) or non-gain group (VO_2peak change ≤1.3 ml.kg^-1.min^-1). Cardiorespiratory fitness (VO_2peak), obtained by the cardiopulmonary exercise test was assessed one and 6 months after the end of the training (short- and long-term detraining, respectively), or collected retrospectively from patient chart (before and after the training).

RESULTS

There was found a significant interaction effect (time*group) for VO_2peak (F= 6.108;p < 0,001). Higher values in the VO_2peak observed in the gain group with the aerobic training (F = 25.86; p< .001) were significantly reduced with short-term detraining, reaching values similar to that observed before the training and to that of the non-gain group (F = 14.81;p= .001). Both groups had similar VO_2peak values within long-term detraining (F = 2.70;p= .12), with no significant differences from the values observed before the training and after short-term detraining (0.11 ≤ p≤ 1.00).

CONCLUSIONS

Detraining on cardiorespiratory fitness of individuals after chronic stroke occurred within only 1 month. Therefore, it is important to maintain aerobic training throughout life.

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).

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.

Effects of High-Intensity Interval Training After Stroke (the HIIT-Stroke Study): A Multicenter Randomized Controlled Trial

OBJECTIVE

To examine if 8 weeks of high-intensity interval training (HIIT) in addition to standard care would increase and maintain peak oxygen uptake (Vo_2peak) more than standard care alone in patients with stroke.

DESIGN

This was a single-blind, multicenter, parallel group, randomized controlled trial.

SETTING

Specialized rehabilitation units at 3 Norwegian hospitals.

PARTICIPANTS

Participants (N=70), 3 months to 5 years after first-ever stroke, were randomly assigned to the intervention group (n=36) or the control group (n=34); 42% were women, mean age was 57.6±9.3 years, mean time post stroke was 26.4±14.5 months.

INTERVENTION

The intervention was 8 weeks: 3 times a week with HIIT treadmill training with work periods of 4 × 4 minutes at 85%-95% of peak heart rate interspersed with 3 minutes of active recovery at 50%-70% of peak heart rate. The control group received standard care according to national guidelines.

OUTCOMES

The primary outcome, analyzed by intention-to-treat, was Vo_2peak measured as liters per minute 12 months after inclusion. Secondary outcome measures were blood pressure and blood profile.

RESULTS

Mean baseline Vo_2peak was 2.63±1.08 L·min^-1 vs 2.87±0.71 L·min^-1, while at 12 months Vo_2peak was 2.70±1.00 L·min^-1 vs 2.67±0.76 L·min^-1 (P=.068) in the intervention and control groups, respectively. There was a significant and greater improvement in the intervention group compared with the control group at 12 months in 3 of 6 secondary outcomes from the peak test but no significant differences for blood pressure or blood profile.

CONCLUSIONS

The HIIT intervention, which was well-tolerated in this sample of well-functioning survivors of stroke, was not superior to standard care in improving and maintaining Vo_2peak at the 12-month follow-up. However, secondary results from the peak test showed a significant improvement from before to immediately after the intervention.

Energy Cost During the 6-Minute Walk Test and Its Relationship to Real-World Walking After Stroke: A Correlational, Cross-Sectional Pilot Study

BACKGROUND

After experiencing stroke, individuals expend more energy walking than people who are healthy. However, among individuals who have experienced stroke, the correlation between the energy cost of walking, as measured by validated tests (such as the 6-minute walk test), and participation in walking, as measured by more sensitive tools (such as an ambulatory activity monitor), remains unknown.

OBJECTIVE

The main objective of this study was to determine whether the energy cost of walking is correlated with participation in walking.

DESIGN

This study was a correlational, cross-sectional pilot study.

METHODS

Data from 23 participants who had experienced chronic stroke were analyzed. On the first day, data on oxygen uptake were collected using a portable metabolic system while participants walked during the 6-minute walk test. Then, the ambulatory activity monitor was placed on the participants' nonparetic ankle and removed 9 days later. The energy cost of walking was calculated by dividing the mean oxygen uptake recorded during the steady state by the walking speed.

RESULTS

The energy cost of walking was correlated with the following: the number of steps (Spearman rank correlation coefficient [rs] = -0.59); the percentage of time spent in inactivity (rs = 0.48), low cadence (rs = 0.67), medium cadence (rs = -0.56), high cadence (rs = -0.65), and the percentages of steps taken at low cadence (rs = 0.65) and high cadence (rs = -0.64).

LIMITATIONS

Individuals who were physically inactive, convenience sampling, and a small sample size were used in this study.

CONCLUSIONS

Higher energy costs of walking were associated with fewer steps per day and lower cadence in real-world walking in individuals who had experienced stroke.

Metabolomics of Aerobic Exercise in Chronic Stroke Survivors: A Pilot Study

BACKGROUND

Understanding the metabolic response to exercise may aid in optimizing stroke management. Therefore, the purpose of this pilot study was to evaluate plasma metabolomic profiles in chronic stroke survivors following aerobic exercise training.

METHODS

Participants (age: 62 ± 1 years, body mass index: 31 ± 1 kg/m², mean ± standard error of the mean) were randomized to 6 months of treadmill exercise (N = 17) or whole-body stretching (N = 8) with preintervention and postintervention measurement of aerobic capacity (VO₂peak). Linear models for microarray data expression analysis was performed to determine metabolic changes over time, and Mummichog was used for pathway enrichment analysis following analysis of plasma samples by high-performance liquid chromatography coupled to ultrahigh resolution mass spectrometry.

RESULTS

VO₂peak change was greater following exercise than stretching (18.9% versus -.2%; P < .01). Pathway enrichment analysis of differentially expressed metabolites results showed significant enrichment in 4 pathways following treadmill exercise, 3 of which (heparan-, chondroitin-, keratan-sulfate degradation) involved connective tissue metabolism and the fourth involve lipid signaling (linoleate metabolism). More pathways were altered in pre and post comparisons of stretching, including branched-chain amino acid, tryptophan, tyrosine, and urea cycle, which could indicate loss of lean body mass.

CONCLUSIONS

These preliminary data show different metabolic changes due to treadmill training and stretching in chronic stroke survivors and suggest that in addition to improved aerobic capacity, weight-bearing activity, like walking, could protect against loss of lean body mass. Future studies are needed to examine the relationship between changes in metabolomic profiles to reductions in cardiometabolic risk after treadmill rehabilitation.

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.

Feasibility and trend of pulmonary function in a pilot trial of aerobic walking exercise in non-ambulatory stroke survivors

Background: Lung function is compromised in stroke survivors, which may cause fatigue and exercise intolerance. Furthermore, past studies of aerobic exercise have involved only stroke survivors who could walk independently. Stroke survivors who were unable to walk were not included in the previous research-investigating changes in lung function from walking exercise interventions. In this pilot study, the feasibility and the effect of aerobic walking exercise on lung function was examined in non-ambulatory stroke survivors using a treadmill, bodyweight support system, and a gait training device.Methods: This study was a single group trial. Eight non-ambulatory stroke survivors (five males, mean age 63.3 ± 13.7 years, seven with ischemic stroke) completed a low intensity walking exercise program (30 min/session; three sessions/week for 8 weeks) and lung function test. Before and after the intervention, vital capacity (VC) and forced vital capacity (FVC) using a spirometer were measured according to the guideline from American Thoracic Society/European Respiratory Society.Results: The rates of compliance and attrition were 100% and 10%; respectively, and no adverse events were reported. There were significant differences between pre- and post-intervention assessments in FVC (p = .09), percentage of predicted VC (p = .08), and percentage of predicted FVC (p = .08).Conclusions: In non-ambulatory stroke survivors, aerobic walking exercise is feasible and safe. Also, the results are promising and suggest that aerobic walking exercise may improve lung function; more data are needed.

Randomized Controlled Trial of the Lateral Push-Off Skater Exercise for High-Intensity Interval Training vs Conventional Treadmill Training

OBJECTIVE

To examine the therapeutic effects of the lateral push-off skater exercise vs conventional treadmill training on health-related quality of life, cardiorespiratory fitness (CRF), and balance.

DESIGN

Single-blinded, randomized controlled trial.

SETTING

Outpatient clinic at a tertiary hospital.

PARTICIPANTS

Patients after minor stroke (N=36) with National Institutes of Health Stroke Scale scores≤3 between 20 and 65 years of age were randomly assigned to the intervention group (n=18) or the control group (n=18).

INTERVENTIONS

Thirty-minute sessions of the skater exercise were performed 3 times weekly for 12 weeks in the intervention group. Conventional treadmill aerobic exercise was conducted in the control group at the same frequency and duration as the experimental group exercise.

MAIN OUTCOME MEASURES

The primary outcome was measured using the European Quality of Life-5 Dimension (EQ-5D). Secondary outcomes included CRF and balance indicators. Assessments were performed at baseline (T0), 12 weeks from T0 (T1), and 16 weeks from T0 (T2).

RESULTS

Significant improvements in EQ-5D, peak oxygen uptake (VO₂peak), peak oxygen pulse, peak minute ventilation (VE), Dynamic Gait Index (DGI), and Berg Balance Scale (BBS) were found in the intervention group after performing the skater exercise (P<.05, all), and these improvements were sustained at T2 (P<.05, all). Between-group comparisons demonstrated greater improvements in EQ-5D, VO₂peak, peak oxygen pulse, peak VE, DGI, and BBS in the intervention group than those in the control group at both T1 (P<.05, all) and T2 (P<0.05, all). Correlation analysis showed significant relationships between EQ-5D and VO₂peak, peak VE, DGI, and BBS (P<.05, all).

CONCLUSIONS

The skater exercise improved health-related quality of life, CRF, and balance in patients after minor stroke more effectively than conventional treadmill-based aerobic exercise. We recommend the skater exercise as a high-intensity interval training program for patients after minor stroke.

High Intensity Exercise for Walking Competency in Individuals with Stroke: A Systematic Review and Meta-Analysis

OBJECTIVE

To assess the effects of high intensity exercise on walking competency in individuals with stroke.

DATA SOURCES

A systematic electronic searching of the PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL (EBSCOhost), and SPORTSDiscus (EBSCOhost) was initially performed up to June 25, 2019.

STUDY SELECTION

Randomized controlled trials or clinical controlled trials comparing any walking or gait parameters of the high intensity exercise to lower intensity exercise or usual physical activities were included. The risk of bias of included studies was assessed by the Cochrane risk of bias tool. The quality of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system.

DATA EXTRACTION

Data were extracted by 2 independent coders. The mean and standard deviation of the baseline and endpoint scores after training for walking distance, comfortable gait speed, gait analysis (cadence, stride length, and the gait symmetry), cost of walking, Berg Balance Scale , Time Up&Go (TUG) Test and adverse events were extracted.

DATA SYNTHESIS

A total of 22 (n = 952) studies were included. Standardized mean difference (SMD), weighted mean difference (WMD), and odds ratios (ORs) were used to compute effect size and subgroup analysis was conducted to test the consistency of results with different characteristics of exercise and time since stroke. Sensitivity analysis was used to assess the robustness of the results, which revealed significant differences on walking distance (SMD = .32, 95% CI, .17-.46, P < .01, I² = 39%; WMD = 21.76 m), comfortable gait speed (SMD = .28, 95% CI, .06-.49, P = .01, I² = 47%; WMD = .04 m/s), stride length (SMD = .51, 95% CI, .13-.88, P < .01, I² = 0%; WMD = .12 m) and TUG (SMD = -.36, 95% CI, -.72 to .01, P = .05, I² = 9%; WMD = -1.89 s) in favor of high intensity exercise versus control group. No significant differences were found between the high intensity exercise and control group in adverse events, including falls (OR = 1.40, 95% CI, .69-2.85, P = .35, I² = 11%), pain (OR = 3.34, 95% CI, .82-13.51, P = .09, I² = 0%), and skin injuries (OR = 1.08, 95% CI, .30-3.90, P = .90, I² = 0%).

CONCLUSIONS

This systematic review suggests that high intensity exercise could be safe and more potent stimulus in enhancing walking competency in stroke survivors, with a capacity to improve walking distance, comfortable gait speed, stride length, and TUG compared with low to moderate intensity exercise or usual physical activities.