Improving physical activity after stroke via treadmill training and self management (IMPACT): a protocol for a randomised controlled trial

Effects of flexor reflex stimulation on gait aspects in stroke patients: randomized clinical trial

BACKGROUND

Gait deficits are very common after stroke and therefore an important aspect in poststroke rehabilitation. A currently little used method in gait rehabilitation after stroke is the activation of the flexor reflex (FR) by electrical stimulation of the sole of foot while walking. The aim of this study was to investigate the effect of FR stimulation on gait performance and gait parameters in participants with stroke within a single session of flexor reflex stimulation using Incedo™.

METHODS

Twenty-five participants with subacute (n = 14) and chronic (n = 11) stroke were enrolled in the study. Motor functions were tested with a 10-m walk test (10mWT), a 2-min walk test (2minWT), and a gait analysis. These tests were performed with and without Incedo™ within a single session in randomized order.

RESULTS

In the 10mWT, a significant difference was found between walking with Incedo™ (15.0 ± 8.5 s) versus without Incedo™ (17.0 ± 11.4 s, p = 0.01). Similarly, the 2minWT showed a significant improvement with Incedo™ use (90.0 ± 36.4 m) compared to without Incedo™ (86.3 ± 36.8 m, p = 0.03). These results indicate that while the improvements are statistically significant, they are modest and should be considered in the context of their clinical relevance. The gait parameters remained unchanged except for the step length. A subgroup analysis indicated that participants with subacute and chronic stroke responded similarly to the stimulation. There was a correlation between the degree of response to electrostimulation while walking and degree of improvement in 2minWT (r = 0.50, p = 0.01).

CONCLUSIONS

This study is the first to examine FR activation effects in chronic stroke patients and suggests that stimulation effects are independent of the time since stroke. A larger controlled clinical trial is warranted that addresses issues as the necessary number of therapeutical sessions and for how long stimulation-induced improvements outlast the treatment period.

TRIAL REGISTRATION

The trial was retrospectively registered in German Clinical Trials Register.

CLINICAL TRIAL REGISTRATION NUMBER

DRKS00021457. Date of registration: 29 June 2020.

Gait Training with Functional Electrical Stimulation Improves Mobility in People Post-Stroke

(1) Background: Stroke is one of the leading causes of disability. To identify the best treatment strategies for people with stroke (PwS), the aim of the current study was to compare the effects of training on a treadmill with functional electrical stimulation (TT-FES) with training on a treadmill (TT), and to analyze the effects of sequence of training on mobility and the parameters of walking ability. (2) Methods: Prospective, longitudinal, randomized and crossover study, in which 28 PwS were distributed into groups, namely the A-B Group (TT-FES followed by TT) and B-A Group (TT followed by TT-FES), using the foot drop stimulator, and were measured with functional tests. (3) Results: We found improved mobility, balance, non-paretic limb coordination, and endurance only in the group that started with TT-FES. However, sensorimotor function improved regardless of the order of training, and paretic limb coordination only improved in the B-A Group, but after TT-FES. These data indicate that the order of the protocols changed the results. (4) Conclusions: Although biomechanical evaluation methods were not used, which can be considered a limitation, our results showed that TT-FES was superior to isolated training on a treadmill with regard to balance, endurance capacity, and coordination of the non-paretic limb.

The Effect of Self-Care Nurturance Using the Theory of Modeling and Role-Modeling on Self-Efficacy in Stroke Patients: A Randomized Controlled Trial

The disability after a stroke results in reduced self-care capacity and lower levels of self-efficacy in survivors. Exploiting a holistic self-care plan to strengthen internal resources in clients can be thus deemed as an effective solution. This study aimed to determine the effect of self-care nurturance using the Theory of Modeling/Role-Modeling (TMRM) on self-efficacy in stroke clients. A randomized controlled trial was conducted at Qaem Hospital, Mashhad, Iran, in 2020. For this purpose, 70 clients were randomly assigned to 2 groups. Then, the experimental group received self-care nurturance based on the TMRM, all through 4 to 6 individual sessions of 30 to 45 minutes in the hospital, and subsequently 2 sessions of telephone counseling up to 8 weeks after the discharge. With reference to patient evaluation in terms of self-care resources, knowledge, and actions, the researcher also tried to strengthen such factors based on the individual needs of each client. The control group received routine care. The data were collected through completing a demographic/disease information form at the onset and the Stroke Self-Efficacy Questionnaire (SSEQ) before the intervention, 4 and 8 weeks after it. The results revealed that the self-efficacy mean scores of the experimental group, in the course of 3 measurement stages, had significantly improved, compared with that in the control group (P = .018). It was concluded that applying the TMRM could strengthen internal and external resources and self-care knowledge in stroke patients, develop their self-care actions, and improve their levels of self-efficacy.

A scoping review on recent trends in wearable sensors to analyze gait in people with stroke: From sensor placement to validation against gold-standard equipment

The purpose of the review is to evaluate wearable sensor placement, their impact and validation of wearable sensors on analyzing gait, primarily the postural instability in people with stroke. Databases, namely PubMed, Cochrane, SpringerLink, and IEEE Xplore were searched to identify related articles published since January 2005. The authors have selected the articles by considering patient characteristics, intervention details, and outcome measurements by following the priorly set inclusion and exclusion criteria. From a total of 1077 articles, 142 were included in this study and classified into functional fields, namely postural stability (PS) assessments, physical activity monitoring (PA), gait pattern classification (GPC), and foot drop correction (FDC). The review covers the types of wearable sensors, their placement, and their performance in terms of reliability and validity. When employing a single wearable sensor, the pelvis and foot were the most used locations for detecting gait asymmetry and kinetic parameters, respectively. Multiple Inertial Measurement Units placed at different body parts were effectively used to estimate postural stability and gait pattern. This review article has compared results of placement of sensors at different locations helping researchers and clinicians to identify the best possible placement for sensors to measure specific kinematic and kinetic parameters in persons with stroke.

Rehabilitation services and related health databases, Japan

The demographic transition towards an ageing population and the epidemiological transition from communicable to noncommunicable diseases have increased the demand for rehabilitation services globally. The aims of this paper were to describe the integration of rehabilitation into the Japanese health system and to illustrate how health information systems containing real-world data can be used to improve rehabilitation services, especially for the ageing population of Japan. In addition, there is an overview of how evidence-informed rehabilitation policy is guided by the analysis of large Japanese health databases, such as: (i) the National Database of Health Insurance Claims and Specific Health Checkups; (ii) the long-term care insurance comprehensive database; and (iii) the Long-Term Care Information System for Evidence database. Especially since the 1990s, the integration of rehabilitation into the Japanese health system has been driven by the country’s ageing population and rehabilitation is today provided widely to an increasing number of older adults. General medical insurance in Japan covers acute and post-acute (or recovery) intensive rehabilitation. Long-term care insurance covers rehabilitation at long-term care institutions and community facilities for older adults with the goal of helping to maintain independence in an ageing population. The analysis of large health databases can be used to improve the management of rehabilitation care services and increase scientific knowledge as well as guide rehabilitation policy and practice. In particular, such analyses could help solve the current challenges of overtreatment and undertreatment by identifying strict criteria for determining who should receive long-term rehabilitation services.

IMproving Physical ACtivity after stroke via Treadmill training (IMPACT) and self-management: a randomised trial

Aim: To determine if treadmill training embedded in self-management education commencing during stroke inpatient rehabilitation results in more physical activity than usual gait training.

Method: A prospective, parallel-group, randomised trial with concealed allocation, blinded measurement and intention-to-treat analysis involving 119 stroke survivors undergoing rehabilitation who were able to walk independently was undertaken. The experimental group undertook treadmill training (40-60% heart rate reserve) and self-management education for 30 minutes, three times a week for 8 weeks and the control group undertook the same amount of usual gait training. Outcomes were measured at baseline (Week 0), on completion of the intervention (Week 8) and beyond the intervention (Week 26). The primary outcome was physical activity measured as steps/day using an activity monitor. Secondary outcomes were walking ability, cardiorespiratory fitness, cardiovascular risk, depression, self-efficacy, perception of physical activity, participation, and quality of life.

Results: After 8 weeks, the experimental group took 1436 more steps/day (95% CI 229 to 2643) than the control group. By 6 months, they took 871 more steps/day (95% CI -385 to 2129) than the control group. There was no difference between groups in any other outcome.

Conclusions: In individuals undergoing rehabilitation after stroke, 8 weeks of treadmill training embedded in self-management resulted in more physical activity than usual gait training and this was largely maintained at 6 months, despite little effect on walking or cardiorespiratory fitness, suggesting the self-management was responsible.

Trial Registration: ACTRN12613000744752.

Data Access: Data are available from the corresponding author.

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.

Continuity of Care and Self-Management among Patients with Stroke: A Cross-Sectional Study

(1) Background: Stroke is an important topic in the healthcare industry. The objective of the present study was to investigate patients' sociodemographic characteristics, health status, continuity of care, self-management, and other predictors that affect their self-management. (2) Methods: This cross-sectional correlational study was carried out from March to September 2020, and included a total of 150 patients aged 20 and above who were diagnosed within the past 6 months. The research participants were selected from the Division of Neurology, Department of Internal Medicine/Department of Surgery, at a medical center in Central Taiwan. (3) Results: The mean self-management score of patients with stroke was 110.50 points (30-150 points). As shown in the stepwise regression analysis, the overall regression model explained approximately 44.5% of the variance in self-management. Educational level (10.8%), frequency of exercise per week (2.1%), time that patients were affected by stroke (2.4%), and continuity of care (29.2%) were the main predictors affecting the self-management of stroke patients. (4) Conclusions: To improve stroke patients' self-management, medical teams should provide appropriate continuity of care to those with lower educational levels, those without exercise habits, and those who experienced a stroke within the past six months.

Interventions for reducing sedentary behaviour in people with stroke

BACKGROUND

Stroke survivors are often physically inactive as well as sedentary,and may sit for long periods of time each day. This increases cardiometabolic risk and has impacts on physical and other functions. Interventions to reduce or interrupt periods of sedentary time, as well as to increase physical activity after stroke, could reduce the risk of secondary cardiovascular events and mortality during life after stroke.

OBJECTIVES

To determine whether interventions designed to reduce sedentary behaviour after stroke, or interventions with the potential to do so, can reduce the risk of death or secondary vascular events, modify cardiovascular risk, and reduce sedentary behaviour.

SEARCH METHODS

In December 2019, we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, Conference Proceedings Citation Index, and PEDro. We also searched registers of ongoing trials, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing interventions to reduce sedentary time with usual care, no intervention, or waiting-list control, attention control, sham intervention or adjunct intervention. We also included interventions intended to fragment or interrupt periods of sedentary behaviour.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and performed 'Risk of bias' assessments. We analyzed data using random-effects meta-analyses and assessed the certainty of the evidence with the GRADE approach.

MAIN RESULTS

We included 10 studies with 753 people with stroke. Five studies used physical activity interventions, four studies used a multicomponent lifestyle intervention, and one study used an intervention to reduce and interrupt sedentary behaviour. In all studies, the risk of bias was high or unclear in two or more domains. Nine studies had high risk of bias in at least one domain. The interventions did not increase or reduce deaths (risk difference (RD) 0.00, 95% confidence interval (CI) -0.02 to 0.03; 10 studies, 753 participants; low-certainty evidence), the incidence of recurrent cardiovascular or cerebrovascular events (RD -0.01, 95% CI -0.04 to 0.01; 10 studies, 753 participants; low-certainty evidence), the incidence of falls (and injuries) (RD 0.00, 95% CI -0.02 to 0.02; 10 studies, 753 participants; low-certainty evidence), or incidence of other adverse events (moderate-certainty evidence). Interventions did not increase or reduce the amount of sedentary behaviour time (mean difference (MD) +0.13 hours/day, 95% CI -0.42 to 0.68; 7 studies, 300 participants; very low-certainty evidence). There were too few data to examine effects on patterns of sedentary behaviour. The effect of interventions on cardiometabolic risk factors allowed very limited meta-analysis.

AUTHORS' CONCLUSIONS

Sedentary behaviour research in stroke seems important, yet the evidence is currently incomplete, and we found no evidence for beneficial effects. Current World Health Organization (WHO) guidelines recommend reducing the amount of sedentary time in people with disabilities, in general. The evidence is currently not strong enough to guide practice on how best to reduce sedentariness specifically in people with stroke. More high-quality randomised trials are needed, particularly involving participants with mobility limitations. Trials should include longer-term interventions specifically targeted at reducing time spent sedentary, risk factor outcomes, objective measures of sedentary behaviour (and physical activity), and long-term follow-up.

Personal and social factors that influence physical activity levels in community-dwelling stroke survivors: A systematic review of qualitative literature

OBJECTIVES

To determine the personal and social factors perceived to influence physical activity levels in stroke survivors.

DATA SOURCES

Four electronic databases (MEDLINE, CINAHL, PubMed and Embase) were searched from inception to November 2020, including reference and citation list searches.

STUDY SELECTION

The initial search yielded 1499 papers, with 14 included in the review. Included articles were peer-reviewed, qualitative studies, reporting on the perceived factors influencing physical activity levels of independently mobile community-dwelling adults, greater than 3 months post stroke.

DATA EXTRACTION

Data extracted included location, study aim, design, participant and recruitment information and how data were collected and analysed.

DATA SYNTHESIS

Thematic analysis was undertaken to identify meanings and patterns, generate codes and develop themes. Five main themes were identified: (i) Social networks are important influencers of physical activity; (ii) Participation in meaningful activities rather than 'exercise' is important; (iii) Self-efficacy promotes physical activity and physical activity enhances self-efficacy; (iv) Pre-stroke identity related to physical activity influences post-stroke physical activity; and (v) Formal programmes are important for those with low self-efficacy or a sedentary pre-stroke identity.

CONCLUSIONS

Physical activity levels in stroke survivors are influenced by social activities and support, pre-stroke identity, self-efficacy levels and completion of activities that are meaningful to stroke survivors.

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.

Recumbent cycling with integrated volitional control electrical stimulation improves gait speed during the recovery stage in stroke patients

The purpose of this study was to investigate the effect of recumbent cycling with integrated volitional control electrical stimulation (IVES) on gait ability in stroke patients. Six stroke patients (all male; average age, 55.7±8.3 years) participated. Recumbent cycling (R-cycling) was performed with and without IVES in the power assist (IVES-P) mode. The targeted muscle for electrostimulation was the tibialis anterior. Patients performed 10 min of IVES-P mode plus R-cycling (program A) or R-cycling alone (program B), once per day, 5 times per week. Patients completed two sets of each program, alternating between programs each week. Gait speed and the number of steps numbers on a 10-m walking test was assessed before and after each interventional session. Program A improved gait speed, but not the number of steps, to a greater extent than that in program B. Specifically, the combined intervention significantly improved gait speed in the first set, but not the second set of the intervention. R-cycling with IVES-P mode improved gait speed during the recovery stage in stroke patients to a greater extent than that achieved with R-cycling alone. Thus, this combined therapy has potential as a standardized treatment in the field of rehabilitation medicine.

A systematic review of measures of adherence to physical exercise recommendations in people with stroke

OBJECTIVE:

To review methods for measuring adherence to exercise or physical activity practice recommendations in the stroke population and evaluate measurement properties of identified tools.

DATA SOURCES:

Two systematic searches were conducted in eight databases (MEDLINE, CINAHL, PsycINFO, Cochrane Library of Systematic Reviews, Sports Discus, PEDro, PubMed and EMBASE). Phase 1 was conducted to identify measures. Phase 2 was conducted to identify studies investigating properties of these measures.

REVIEW METHODS:

Phase 1 articles were selected if they were published in English, included participants with stroke, quantified adherence to exercise or physical activity recommendations, were patient or clinician reported, were defined and reproducible measures and included patients >18 years old. In phase 2, articles were included if they explored psychometric properties of the identified tools. Included articles were screened based on title/abstract and full-text review by two independent reviewers.

RESULTS:

In phase 1, seven methods of adherence measurement were identified, including logbooks ( n = 16), diaries ( n = 18), 'record of practice' ( n = 3), journals ( n = 1), surveys ( n = 2) and questionnaires ( n = 4). One measurement tool was identified, the Physical Activity Scale for Individuals with Physical Disabilities ( n = 4). In phase 2, no eligible studies were identified.

CONCLUSION:

There is not a consistent measure of adherence that is currently utilized. Diaries and logbooks are the most frequently utilized tools.

Exercise for stroke prevention

We review evidence concerning exercise for stroke prevention. Plausible biological reasons suggest that exercise would be important in preventing stroke. While definitive randomised controlled trials evaluating the impact of physical activity (PA) and exercise on preventing stroke and mortality are lacking, observational studies, small randomised controlled trials and meta-analyses have provided evidence that PA and exercise favourably modify stroke risk factors, including hypertension, dyslipidaemia, diabetes, sedentary lifestyle, obesity, excessive alcohol consumption and tobacco use. It is, therefore, important to understand the factors associated with poststroke PA/exercise and cardiorespiratory fitness. Positively associated factors include self-efficacy, social support and quality of patients' relationships with health professionals. Negatively associated factors include logistical barriers, medical comorbidities, stroke-related deficits, negative exercise beliefs, fear of falling, poststroke fatigue, arthropathy/pain and depression. Definitive research is needed to specify efficacious behavioural approaches to increase poststroke exercise. Effective techniques probably include physician endorsement of exercise programmesto patients, enhancement of patient-professional relationships, providing patients an exercise rationale, motivational interviewing, collaborative goal-setting with patients, addressing logistical concerns, social support in programsmes, structured exercise programming, individualised behavioural instruction, behavioural diary recording, reviewing behavioural consequences of exercise efforts, reinforcing successful exercise performance. Exercise programming without counselling may increase short-term activity; simple advice or information-giving is probably ineffective. Older patients or those with cognitive impairment may need increased structure, with emphasis on behaviour per se, versus self-regulation skills. We support the latest American Heart Association/American Stroke Association guidelines (2014) recommending PA and exercise for stroke prevention, and referral to behaviourally oriented programmes to improve PA and exercise.