A systematic review of exercise trials post stroke

The effectiveness of group exercise for improving activity and participation in adult stroke survivors: a systematic review

BACKGROUND

Following post stroke rehabilitation, group exercise interventions can be used to continue improving cardiovascular fitness, activity levels, balance, gait, movement efficiency, and strengthening. However, little is known of the effectiveness of group exercise for improving activity and participation in stroke survivors.

OBJECTIVES

This review aims to assess the effectiveness of group exercise for improving activity and participation in adult stroke survivors.

DATA SOURCES

Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library.

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) of group exercise using validated outcome measures of activity and participation for post stroke rehabilitation. Two independent reviewers assessed all abstracts, extracted data, conducted a narrative synthesis and assessed the quality of all included articles. The Cochrane Risk of Bias Tool assessed methodological quality and included outcome measure quality was assessed.

RESULTS

14 RCTs were included (n=624 chronic stroke survivors collectively). Studies ranged between 12 and 243 stroke participants with an average of left:right hemisphere lesions of 32:39 and average age was 66.7 years. Although intervention and control groups improved, no significant difference between group differences were evident.

CONCLUSION

and implications of key findings: The review found improvements are short-term and less evident at long-term follow up with little improvements in participation after 6months. However, this review was limited to the standard of intervention reporting. Further research should consider consistency in measuring underpinning mechanisms of group exercise interventions, which may explain the lack of activity changes in long-term follow-up.

SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO

CRD42017078917.

High intensity exercise preconditioning provides differential protection against brain injury following experimental stroke

AIMS

Different modes of physical activity provide cerebrovascular protection against thromboembolic events. Based on recent reports high intensity exercise protocols appear to raise cerebral VEGF levels leading to efficient cerebral angiogenesis. The present study aims to address if moderate continuous training (MCT) and high intensity interval training (HIT) differ in preconditioning against ischemic stroke.

METHODS

Wistar rats were subjected to HIT or MCT for 8 weeks before transient middle cerebral artery occlusion (tMCAO) surgery. As indexes for improved angiogenic signals, VEGF-A and its pivotal receptor VEGF-R2 were immunoblotted just before occlusive stroke.

KEY FINDINGS

Both training protocols induced a remarkable protection against neurological deficit and tissue injury following stroke. Cerebral infarctions were better improved in HIT animals which explained the slightly but not significantly higher neurological function. HIT brains developed higher levels of cortical VEGF-A and striatal VEGF-R2.

SIGNIFICANCE

These data conclude preconditioning with high intensity protocols might excel continued moderate exercise to induce VEGF signaling and alleviate stroke outcomes. Further investigations may provide complementary mechanistic views.

Interventions to Improve Movement and Functional Outcomes in Adult Stroke Rehabilitation: Review and Evidence Summary

Background

Patients who have had a stroke may not be familiar with the terminology nor have the resources to efficiently search for evidence-based rehabilitation therapies to restore movement and functional outcomes. Recognizing that a thorough systematic review on this topic is beyond the scope of this article, we conducted a rapid review evidence summary to determine the level of evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Objective

The objective of this study was to find evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Methods

Medline Complete, PubMed, CINAHL Complete, Cochrane Database, Rehabilitation and Sports Medicine Source, Dissertation Abstracts International, and National Guideline Clearinghouse, from 1996 to April of 2016, were searched. From 348 articles, 173 met the following inclusion criteria: (1) published systematic reviews or meta-analyses, (2) outcomes target functional movement or motor skills of the upper and lower limbs, (3) non-pharmacological interventions that are commonly delivered to post-stroke population (acute and chronic), (4) human studies, and (5) English. Evidence tables were created to analyze the findings of systematic reviews and meta-analyses by category of interventions and outcomes.

Results

This rapid review found that the following interventions possess credible evidence to improve functional movement of persons with stroke: cardiorespiratory training, therapeutic exercise (ie, strengthening), task-oriented training (task-specific training), constraint-induced movement therapy (CIMT), mental practice, and mirror therapy. Neuromuscular electrical stimulation (NMES) (ie, functional electrical stimulation) shows promise as an intervention for stroke survivors.

Conclusions

Most commonly delivered therapeutic interventions to improve motor recovery after a stroke possess moderate quality evidence and are effective. Future research recommendations, such as optimal timing and dosage, would help rehabilitation professionals tailor interventions to achieve the best outcomes for stroke survivors.

Cardiorespiratory fitness and walking endurance improvements after 12 months of an individualised home and community-based exercise programme for people after stroke

OBJECTIVE

To evaluate the immediate and longer-term effects of an individually tailored, home- and community-based exercise programme with ongoing remote support in people with stroke on cardiorespiratory fitness (CRF), ambulation and health-related quality of life (HRQoL).

METHODS

Twenty people 5.3 ± 3.5 months post stroke completed the 12-week HowFITSS? exercise programme aimed at increasing CRF and daily physical activity. Support was provided by phone and email, which decreased in frequency over time. Participants were assessed at baseline, then at 3, 6 and 12 months after initiation of the intervention. CRF (VO_2peak) was evaluated using a portable metabolic system during the 6-minute walk test (6MWT), the Shuttle Walk Test (SWT) and the cycle graded exercise test (cGXT). Walking speed, balance, body composition, fatigue, depression and HRQoL were also measured.

RESULTS

CRF improved significantly from pre-intervention to 12-month follow-up on the 6MWT (Effect Size, ES = 0.87; p = 0.002) and cGXT (ES = 0.60; p < 0.001), with more modest improvements on the SWT (ES = 0.52; p = 0.251). From baseline to 12 months, significant within-participant improvements were found for self-selected walking speed, balance and HRQoL. Performances on the remaining tests were maintained over the post-intervention period.

CONCLUSION

There may be health benefits of providing people with stroke an exercise intervention with long-term support that encourages increased regular physical activity.

One session of whole body vibration increases voluntary muscle strength transiently in patients with stroke

Objective: To determine the effect of whole body vibration on isometric and eccentric torque and electromyography (EMG) variables of knee extensors on the affected side of stroke patients.

Design: A randomized controlled study.

Setting: A rehabilitation centre.

Subjects: Sixteen patients (age 58.2 ± 9.4 years) were enrolled in an inpatient rehabilitation programme 27.2 ± 10.4 days after a stroke.

Interventions: Eight patients were randomly assigned to the vibration group and received 20 Hz vibration (5 mm amplitude) while standing on a vibration platform for 1 minute six times in one session. Patients in the control group also stood on the platform but did not receive vibration.

Main measures: Maximum isometric and eccentric torque, rate of torque development, root-mean-squared EMG, median frequency of vastus lateralis, and co-activation of knee flexors.

Results: Isometric and eccentric knee extension torque increased 36.6% and 22.2%, respectively, after vibration (P < 0.05) and 8.4% and 5.3% in the control group. Vibration increased EMG amplitude 44.9% and the median frequency in the vastus lateralis by 13.1% (all P < 0.05) without changes in the control group (10.6% and 3.9%). Vibration improved the ability to generate mechanical work during eccentric contraction (17.5%). Vibration reduced biceps femoris co-activation during isometric (8.4%, ns) and eccentric (22.5%, P < 0.05) contraction.

Conclusion: These results suggest that one bout of whole body vibration can transiently increase voluntary force and muscle activation of the quadriceps muscle affected by a stroke.

Effects of Functional Limb Overloading on Symmetrical Weight Bearing, Walking Speed, Perceived Mobility, and Community Participation among Patients with Chronic Stroke

Background. Stroke is a leading cause for long-term disability that often compromises the sensorimotor and gait function accompanied by spasticity. Gait abnormalities persist through the chronic stages of the condition and only a small percentage of these persons are able to walk functionally in the community. Material and Method. Patients with chronic stroke were recruited from outpatient rehabilitation unit at Department of Neurology & Neurosurgery, All India Institute of Medical Sciences, having a history of first stroke at least six months before recruitment, with unilateral motor deficits affecting gait. The patients were randomly assigned to either the functional limb overloading (FLO) or Limb Overloading Resistance Training (LORT) group and provided four weeks of training. Result. We found that there was an improvement in gait performance, weight bearing on affected limb, and perceived mobility and community participation. Conclusion. To the best of our knowledge, this is the first study that has evaluated the effects of functional limb overloading training on symmetric weight bearing, walking ability, and perceived mobility and participation in chronic hemiplegic population. The study demonstrated a beneficial effect of training on all the outcomes, suggesting that the functional limb overloading training can be a useful tool in the management of gait problems in chronic stroke patients.

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

BACKGROUND AND PURPOSE

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

METHOD

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

Cardiovascular Health and Fitness After Stroke

Stroke patients have profound cardiovascular and muscular deconditioning, with metabolic fitness levels that are about half those found in age-matched sedentary controls. Physical deconditioning, along with elevated energy demands of hemiparetic gait, define a detrimental combination termed diminished physiological fitness reserve that can greatly limit that can greatly limit performance of activities of daily living. The physiological features that underlie worsening metabolic fitness in the chronic phase of stroke include gross muscular atrophy, altered muscle molecular phenotype, increased intramuscular area fat, elevated tissue inflammatory markers, and diminished peripheral blood flow dynamics. Epidemiological evidence further suggests that the reduced cardiovascular fitness and secondary biological changes in muscle may propagate components of the metabolic syndrome, conferring added morbidity and mortality risk. This article reviews some of the consequences of poor fitness in chronic stroke and the potential biological underpinnings that support a rationale for more aggressive approaches to exercise therapy in this population.

Effect of task-oriented training for people with stroke: a meta-analysis focused on repetitive or circuit training

PURPOSE

The current meta-analysis reviewed evidence for effective task-oriented training focused on repetitive or circuit training after stroke.

METHOD

Searches were conducted of randomized, controlled trials using task-oriented training. The quality of each study was assessed using the Physiotherapy Evidence Database (PEDro) scale. Eleven studies were analyzed regarding the magnitude of effect sizes (ESs) and categorized according to extremities focused upon for training, outcome measures, and study variables. This included duration and frequency of training and stroke stage.

RESULTS

The PEDro scores ranged from 4 to 8 (median = 7). The overall ES of the 11 studies was large. The effects for lower extremities and both acute/sub-acute and chronic stage stroke were large and significant. Significant effects were also found for gait velocity, gait endurance, balance, timed up and go test, and strength of the lower extremities. There was no significant effect of training focused on upper extremities. Training with a duration of 2 weeks and frequency of 7 days a week had the greatest effects.

CONCLUSIONS

Task-oriented training interventions are useful for improving muscle strength and gait related activities in both acute/sub-acute and chronic stroke patients. Although this meta-analysis provides evidence of task-oriented training for improving functioning after stroke, further studies are necessary to investigate the effects of training on upper extremities and the overall cost-effectiveness of such training.

Evidence-based risk assessment and recommendations for physical activity clearance: stroke and spinal cord injury

Physical activity (PA) has potential benefits after stroke or spinal cord injury (SCI), especially in improving efficiency and functional capacity in activities of daily living. Currently, many who could benefit from PA may be routinely excluded from participation because of myths related to functional capacity and the concern for harm. The purpose of this review was to evaluate the literature for reports of adverse events during exercise after stroke or SCI, and to provide recommendations regarding exercise participation in supervised and unsupervised environments. Studies were evaluated for quality, and the summary level and quality of evidence were evaluated using the AGREE rubric, modified to address the main outcome measure of adverse events. Levels of exercise stress were evaluated for aerobic activities, using an established rubric. Included in the current analysis were 32 studies for stroke and 4 for SCI. In aggregate, this yielded a total of 730 experimental participants with stroke and 143 with SCI. It should be noted that almost all studies were not designed to examine naturally occurring adverse events from PA. Significant contraindications to unsupervised exercise include manifestation of autonomic dysreflexia in SCI and cardiovascular comorbidity after stroke. There are clear benefits of exercise training on physiological outcomes in stroke and SCI, but the relation between outcomes and safety remains unclear. However, taken on balance, the risk-to-benefit ratio favors the recommendation of exercise. This recommendation is based on studies in which participants were almost universally screened for participation in supervised environments. Thus, the grading of evidence for finding adverse events to support this conclusion is inadequate.

Rehabilitation of gait after stroke: a review towards a top-down approach

This document provides a review of the techniques and therapies used in gait rehabilitation after stroke. It also examines the possible benefits of including assistive robotic devices and brain-computer interfaces in this field, according to a top-down approach, in which rehabilitation is driven by neural plasticity.The methods reviewed comprise classical gait rehabilitation techniques (neurophysiological and motor learning approaches), functional electrical stimulation (FES), robotic devices, and brain-computer interfaces (BCI).From the analysis of these approaches, we can draw the following conclusions. Regarding classical rehabilitation techniques, there is insufficient evidence to state that a particular approach is more effective in promoting gait recovery than other. Combination of different rehabilitation strategies seems to be more effective than over-ground gait training alone. Robotic devices need further research to show their suitability for walking training and their effects on over-ground gait. The use of FES combined with different walking retraining strategies has shown to result in improvements in hemiplegic gait. Reports on non-invasive BCIs for stroke recovery are limited to the rehabilitation of upper limbs; however, some works suggest that there might be a common mechanism which influences upper and lower limb recovery simultaneously, independently of the limb chosen for the rehabilitation therapy. Functional near infrared spectroscopy (fNIRS) enables researchers to detect signals from specific regions of the cortex during performance of motor activities for the development of future BCIs. Future research would make possible to analyze the impact of rehabilitation on brain plasticity, in order to adapt treatment resources to meet the needs of each patient and to optimize the recovery process.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability.

OBJECTIVES

To determine whether fitness training after stroke reduces death, dependence, and disability. The secondary aims were to determine the effects of training on physical fitness, mobility, physical function, quality of life, mood, and incidence of adverse events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched April 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, July 2010), MEDLINE (1966 to March 2010), EMBASE (1980 to March 2010), CINAHL (1982 to March 2010), SPORTDiscus (1949 to March 2010), and five additional databases (March 2010). We also searched ongoing trials registers, handsearched relevant journals 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, with no intervention, a non-exercise intervention, or usual care in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality, and extracted data. We analysed data using random-effects meta-analyses. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 32 trials, involving 1414 participants, which comprised cardiorespiratory (14 trials, 651 participants), resistance (seven trials, 246 participants), and mixed training interventions (11 trials, 517 participants). Five deaths were reported at the end of the intervention and nine at the end of follow-up. No dependence data were reported. Diverse outcome measures made data pooling difficult. The majority of the estimates of effect were not significant. Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 8.66 metres per minute, 95% confidence interval (CI) 2.98 to 14.34), preferred gait speed (MD 4.68 metres per minute, 95% CI 1.40 to 7.96) and walking capacity (MD 47.13 metres per six minutes, 95% CI 19.39 to 74.88) at the end of the intervention. These training effects were retained at the end of follow-up. Mixed training, involving walking, increased preferred walking speed (MD 2.93 metres per minute, 95% CI 0.02 to 5.84) and walking capacity (MD 30.59 metres per six minutes, 95% CI 8.90 to 52.28) but effects were smaller and there was heterogeneity amongst the trial results. There were insufficient data to assess the effects of resistance training. The variability in the quality of included trials hampered the reliability and generalizability of the observed results.

AUTHORS' CONCLUSIONS

The effects of training on death, dependence, and disability after stroke are unclear. There is sufficient evidence to incorporate cardiorespiratory training involving walking within post-stroke rehabilitation programmes to improve speed, tolerance, and independence during walking. Further well-designed trials are needed to determine the optimal exercise prescription and identify long-term benefits.

Cardiopulmonary response to exercise testing in people with chronic stroke: a retrospective study

Background and Purpose. This study investigated the cardiopulmonary response and safety of exercise testing at peak effort in people during the chronic stage of stroke recovery. Methods. This retrospective study examined data from 62 individuals with chronic stroke (males: 32; mean (SD); age: (12.0) yr) participating in an exercise test. Results. Both males and females had low cardiorespiratory fitness levels. No significant differences were found between gender for peak HR (P = 0.27), or VO(2) peak (P = 0.29). Males demonstrated higher values for minute ventilation, tidal volume, and respiratory exchange ratio. No major adverse events were observed in the exercise tests conducted. Discussion and Conclusion. There are differences between gender that may play a role in exercise testing performance and should be considered when developing exercise programs. The low VO(2) peak of this cohort of chronic stroke survivors suggests the need for participation in exercise interventions.

Effects of exercise on quality of life in stroke survivors: a meta-analysis

BACKGROUND AND PURPOSE

One of the major consequences after stroke is the deterioration in health-related quality of life (HRQOL). Three previous systematic reviews indicated that exercise has limited to no effect in improving HRQOL in stroke survivors. The objective of this meta-analysis was to update the evidence on exercise and HRQOL in stroke survivors with additional new information on randomized controlled trials that have been published since these 3 previous reviews.

METHODS

MEDLINE, Cumulated Index to Nursing and Allied Health Literature, EMBASE, and SportsDiscus databases were searched for randomized controlled trials reporting the effects of exercise on HRQOL in stroke survivors from 1950 to March 2010. The methodological quality of each study was appraised using the Physiotherapy Evidence Database scale. Standardized mean difference was used to compute effect size and subgroup analysis was conducted to test the consistency of results across the subgroups with different characteristics.

RESULTS

A total of 1101 citations was identified and 9 studies met all criteria for a total sample of 426 stroke survivors. Eight studies were rated as good quality (ie, Physiotherapy Evidence Database scale ≥5). This meta-analysis provided evidence that exercise can have a small to medium effect on HRQOL outcomes (standardized mean difference, 0.32, P<0.01) at postintervention but not at follow-up after exercise was terminated (standardized mean difference, 0.17, P=0.12). No adverse events related to exercise were reported.

CONCLUSIONS

The results provide moderate support for the use of exercise to improve HRQOL in stroke survivors. However, the challenge for researchers is identifying effective strategies for sustaining these effects postintervention.

Rehabilitation of gait speed after stroke: a critical review of intervention approaches

PURPOSE

Walking speed is a cardinal indicator of poststroke gait performance; however, no consensus exists regarding the optimal treatment method(s) for its enhancement. The most widely accepted criterion for establishing the contribution of treatment to walking speed is the gain in speed. The actual speed, however, at the end of the intervention (final speed) may be more important for functional community ambulation. This review examines the contribution of the prevailing methods for gait rehabilitation to final walking speed.

METHOD

Walking speed information was derived from studies included in meta-analyses, systematic reviews, and clinical practice guidelines. Recent references, not included in the mentioned sources, were incorporated in cases when gait speed was an outcome variable. Final speed was assessed by the reported speed values and by inferring the capacity for functional community walking at the end of the intervention period.

RESULTS

Similar outcomes for final walking speed were found for the different prevailing treatment methods. Treatment gains were likewise comparable and generally insufficient for upgrading patients' functional community walking capacity.

CONCLUSIONS

Different treatment methods exist for poststroke gait rehabilitation. Their availability, mode of application, and costs vary, yet outcomes are largely similar. Therefore, choosing an appropriate method may be guided by a pragmatic approach. Simple "low technology" and conventional exercise to date is at least as efficacious as more complex strategies such as treadmill and robotic-based interventions.

Physical fitness training for stroke patients

BACKGROUND

Physical fitness is low after stroke. It is unknown whether improving physical fitness after stroke reduces disability.

OBJECTIVES

To determine whether fitness training (cardiorespiratory or strength, or both) after stroke reduces death, dependence and disability. The secondary aims were to determine the effects of fitness training on physical fitness, mobility, physical function, health status and quality of life, mood and incidence of adverse events.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched March 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2007), MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007), CINAHL (1982 to March 2007), and six additional databases to March 2007. We handsearched relevant journals and conference proceedings, and screened bibliographies. We searched trials registers and contacted experts in the field.

SELECTION CRITERIA

We included randomised controlled trials if the aim of the intervention was to improve muscle strength or cardiorespiratory fitness, or both, and if the control groups comprised either no intervention, usual care or a non-exercise intervention.

DATA COLLECTION AND ANALYSIS

Two review authors determined trial eligibility and quality. One review author extracted outcome data at end of intervention and follow-up scores, or as change from baseline scores. Diverse outcome measures limited the intended analysis.

MAIN RESULTS

We included 24 trials, involving 1147 participants, comprising cardiorespiratory (11 trials, 692 participants), strength (four trials, 158 participants) and mixed training interventions (nine trials, 360 participants). Death was infrequent at the end of the intervention (1/1147) and follow up (8/627). No dependence data were reported. Diverse disability measures made meta-analysis difficult; the majority of effect sizes were not significant. Cardiorespiratory training involving walking, improved maximum walking speed (mean difference (MD) 6.47 metres per minute, 95% confidence interval (CI) 2.37 to 10.57), walking endurance (MD 38.9 metres per six minutes, 95% CI 14.3 to 63.5), and reduced dependence during walking (Functional Ambulation Categories MD 0.72, 95% CI 0.46 to 0.98). Current data include few strength training trials, and lack non-exercise attention controls, long-term training and follow up.

AUTHORS' CONCLUSIONS

The effects of training on death, dependence and disability after stroke are unclear. There is sufficient evidence to incorporate cardiorespiratory training, involving walking, within post-stroke rehabilitation in order to improve speed, tolerance and independence during walking. Further trials are needed to determine the optimal exercise prescription after stroke and identify any long-term benefits.

An approach to standardize, quantify and record progress of routine upper limb therapy for stroke subjects: The Action Medical Research Upper Limb Therapy protocol

Introduction.

Explicitly describing therapy for research purposes, in terms of content and quantity, improves the validity of research and facilitates evidence-based clinical practice. However, such descriptions are not common in therapy research. The aim was to develop an upper limb therapy protocol which reflected local clinical practice in the stroke unit, and a recording form to document the content, quantity and progression of therapy.

Methods.

This was a multi-method study. A list of interventions commonly used for the rehabilitation of the stroke upper limb was compiled following a systematic literature search. This was then refined into the Action Medical Research Upper Limb Therapy (AMRULT) protocol in a two-stage process involving a survey and a group discussion. Six physical therapists and three occupational therapists supported its development. The AMRULT protocol was then piloted in a two-arm randomized controlled trial with 90 stroke patients for therapy and recording purposes.

Results.

The protocol classified therapies based on therapy input as passive, active assisted, active/strengthening and functional. Using this form it was possible to not only summarize the content of therapy but also objectively document progression (e.g. 14% of the participants progressed to functional exercises between the 5th and 8th weeks after stroke onset).

Discussion.

The AMRULT protocol and associated recording form were useful in both standardizing the delivery and quantification (content and progression) of therapy. While the AMRULT protocol was devised for a specific purpose, the method used can be adapted to develop protocols to support other research studies.

Cost-effectiveness of a structured progressive task-oriented circuit class training programme to enhance walking competency after stroke: the protocol of the FIT-Stroke trial

Background

Most patients who suffer a stroke experience reduced walking competency and health-related quality of life (HRQoL). A key factor in effective stroke rehabilitation is intensive, task-specific training. Recent studies suggest that intensive, patient-tailored training can be organized as a circuit with a series of task-oriented workstations.

Primary aim of the FIT-Stroke trial is to evaluate the effects and cost-effectiveness of a structured, progressive task-oriented circuit class training (CCT) programme, compared to usual physiotherapeutic care during outpatient rehabilitation in a rehabilitation centre. The task-oriented CCT will be applied in groups of 4 to 6 patients. Outcome will be defined in terms of gait and gait-related ADLs after stroke. The trial will also investigate the generalizability of treatment effects of task-oriented CCT in terms of perceived fatigue, anxiety, depression and perceived HRQoL.

Methods/design

The multicentre single-blinded randomized trial will include 220 stroke patients discharged to the community from inpatient rehabilitation, who are able to communicate and walk at least 10 m without physical, hands-on assistance. After discharge from inpatient rehabilitation, patients in the experimental group will receive task-oriented CCT two times a week for 12 weeks at the physiotherapy department of the rehabilitation centre. Control group patients will receive usual individual, face-to-face, physiotherapy. Costs will be evaluated by having each patient keep a cost diary for the first 24 weeks after randomisation. Primary outcomes are the mobility part of the Stroke Impact Scale (SIS-3.0) and the EuroQol. Secondary outcomes are the other domains of SIS-3.0, lower limb muscle strength, walking endurance, gait speed, balance, confidence not to fall, instrumental ADL, fatigue, anxiety, depression and HRQoL.

Discussion

Based on assumptions about the effect of intensity of practice and specificity of treatment effects, FIT-Stroke will address two key aims. The first aim is to investigate the effects of task-oriented CCT on walking competency and HRQoL compared to usual face-to-face physiotherapy. The second aim is to reveal the cost-effectiveness of task-oriented CCT in the first 6 months post stroke. Both aims were recently recommended as priorities by the American Hearth Association and Stroke Council.

Trial registration

This study is registered in the Dutch Trial Register as NTR1534.

Immediate and long-term functional impact of repetitive locomotor training as an adjunct to conventional physiotherapy for non-ambulatory patients after stroke

PURPOSE

The aim of the present study was to assess the heart rate intensity during gait training and to evaluate the relationship between heart rate intensity during gait training and walking ability of patients after stroke.

METHODS

We included non-ambulatory patients within six weeks after first stroke. Over four weeks patients were trained five times a week, with either 20 minutes of repetitive locomotor training and 25 min of physiotherapy (RLT-PT), or 45 min of PT alone. We assessed the heart rate intensity during training period. Additionally we assessed walking ability (Functional Ambulation Categories) and the rate of independent ability to perform activities of daily life (Barthel Index) at the end of study and six months and three years later on.

RESULTS

We included 30 patients in each group. Patients in RLT-PT group exercised longer in the HR target zone than in the PT group (16.1+/-11.8 min vs. 5.3+/-5.6 min, p<0.001). Higher heart rates were associated with independent walking at the end of study, at six months and at three years after the end of study (Fishers exact test, p=0.014, p=0.012 and p=0.017, respectively).

CONCLUSIONS

Higher heart rate intensities during gait-training of non-ambulatory post-stroke patients may improve walking function.

A preliminary study to examine the effects of aerobic and therapeutic (nonaerobic) exercise on cardiorespiratory fitness and coronary risk reduction in stroke survivors

OBJECTIVES

To compare the effects of 3 different exercise training regimens on cardiorespiratory fitness and coronary risk factor reduction in subjects with unilateral stroke.

DESIGN

A cluster assignment by residential location repeated-measures design.

SETTING

University-based medical center.

PARTICIPANTS

Fifty-five subjects with unilateral ischemic stroke were assigned to the following groups: intensity (n=18), duration (n=19), and therapeutic exercise (n=18).

INTERVENTION

A 14-week intervention with subjects randomized to 1 of 3 interventions: (1) moderate intensity, shorter duration (MISD) exercise (gradually increasing exercise intensity while keeping exercise duration constant at 30 min), (2) low-intensity, longer duration (LILD) exercise (gradually increasing duration to 60 min while keeping exercise intensity constant), or (3) conventional therapeutic exercise (TE) consisting mainly of strength, balance, and range of motion activities. All groups exercised 3 days per week.

MAIN OUTCOME MEASURES

Peak oxygen consumption (VO2peak), submaximal oxygen consumption (VO2), lipid panel, and resting blood pressure.

RESULTS

The MISD group attained more favorable effects on systolic (P<.04) and diastolic blood pressure (P<.002) and total cholesterol (TC) (P<.036) compared with LILD and TE groups. Both MISD (P<.029) and LILD (P<.045) showed significant reductions in triglycerides compared with TE (P<.029). There was no significant change in VO2peak and submaximal VO2 in any of the groups.

CONCLUSIONS

Overall, both MISD and LILD conditions achieved greater clinical and significant gains in coronary risk reduction compared with TE.

Health benefits of physical activity in older patients: a review

As the number of elderly persons in our country increases, more attention is being given to geriatric healthcare needs and successful ageing is becoming an important topic in medical literature. Concept of successful ageing is in first line on a preventive approach of care for older people. Promotion of regular physical activity is one of the main non-pharmaceutical measures proposed to older subjects as low rate of physical activity is frequently noticed in this age group. Moderate but regular physical activity is associated with a reduction in total mortality among older people, a positive effect on primary prevention of coronary heart disease and a significant benefit on the lipid profile. Improving body composition with a reduction in fat mass, reducing blood pressure and prevention of stroke, as well as type 2 diabetes, are also well established. Prevention of some cancers (especially that of breast and colon), increasing bone density and prevention of falls are also reported. Moreover, some longitudinal studies suggest that physical activity is linked to a reduced risk of developing dementia and Alzheimer's disease in particular.

Repetitive task training for improving functional ability after stroke

BACKGROUND

The active practice of task-specific motor activities is a component of current approaches to stroke rehabilitation.

OBJECTIVES

To determine if repetitive task training after stroke improves global, upper or lower limb function, and if treatment effects are dependent on the amount, type or timing of practice.

SEARCH STRATEGY

We searched the Cochrane Stroke Trials Register (October 2006), The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, SportDiscus, Science Citation Index, Index to Theses, ZETOC, PEDro, and OT Seeker (to September 2006), and OT search (to March 2006). We also searched for unpublished/non-English language trials, conference proceedings, combed reference lists, requested information on bulletin boards, and contacted trial authors.

SELECTION CRITERIA

Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal, and where the amount of practice could be quantified.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts, extracted data and appraised trials. Assessment of methodological quality was undertaken for allocation concealment, blinding, loss to follow up and equivalence of treatment. We contacted trial authors for additional information.

MAIN RESULTS

Fourteen trials with 17 intervention-control pairs and 659 participants were included.

PRIMARY OUTCOMES

results were statistically significant for walking distance (mean difference (MD) 54.6, 95% CI 17.5 to 91.7); walking speed (standardised mean difference (SMD) 0.29, 95% CI 0.04 to 0.53); sit-to-stand (standard effect estimate 0.35, 95% CI 0.13 to 0.56); and of borderline statistical significance for functional ambulation (SMD 0.25, 95% CI 0.00 to 0.51), and global motor function (SMD 0.32, 95% CI -0.01 to 0.66). There were no statistically significant differences for hand/arm function, or sitting balance/reach.

SECONDARY OUTCOMES

results were statistically significant for activities of daily living (SMD 0.29, 95% CI 0.07 to 0.51), but not for quality of life or impairment measures. There was no evidence of adverse effects. Follow-up measures were not significant for any outcome at six or twelve months. Treatment effects were not modified by intervention amount or timing, but were modified by intervention type for lower limbs.

AUTHORS' CONCLUSIONS

Repetitive task training resulted in modest improvement in lower limb function, but not upper limb function. Training may be sufficient to impact on daily living function. However, there is no evidence that improvements are sustained once training has ended. The review potentially investigates task specificity rather more than repetition. Further research should focus on the type and amount of training, and how to maintain functional gain.

Low intensity strength training for ambulatory stroke patients

PURPOSE

To investigate feasibility and effectiveness of an individually-directed, group strength-training programme on knee muscle strength after stroke.

METHOD

Ten volunteers (62 +/- 11 years, mean +/- SD), 6 - 12 months after first-ever unilateral stroke, walking independently with or without aids were recruited. Using an A1-B-A2 design, 3 sets of baseline measures were taken at 2 weekly intervals; volunteers then attended twice weekly sessions of low intensity progressive strengthening exercises and were assessed after each series of 8 sessions to a maximum of 24 sessions; post training, measures were repeated after 4 - 6 weeks. Measures included isometric and concentric knee extensor muscle strength and 10 m walking velocity.

RESULTS

Strength of knee extensor muscles was improved after training (ANOVA, p < 0.05). On cessation of training, isometric strength increased by 58 +/- 19% and concentric strength at 30 degrees /s by 51 +/- 14%; walking velocity quickened from 0.47 +/- 0.06 m x s-1 to 0.57 +/- 0.08 m x s-1 (t = -3.31, p < 0.01). These gains were maintained 4 - 6 weeks after completion of training.

CONCLUSIONS

These findings support the use of low intensity strength training after stroke and confirm published evidence. It was feasible for one therapist to deliver the training programmes for 4 - 6 participants at a time; an important feature when resources are limited.

The use of aerobic exercise training in improving aerobic capacity in individuals with stroke: a meta-analysis

OBJECTIVE

To determine whether aerobic exercise improves aerobic capacity in individuals with stroke.

DESIGN

A systematic review of randomized controlled trials. DATABASES SEARCHED: MEDLINE, CINAHL, EMBASE, Cochrane Database of Systematic Reviews and Physiotherapy Evidence Database were searched.

INCLUSION CRITERIA

Design: randomized controlled trials (RCTs).

PARTICIPANTS

individuals with stroke.

INTERVENTIONS

aerobic exercise training aimed at improving aerobic capacity.

OUTCOMES

PRIMARY OUTCOMES

aerobic capacity (peak oxygen consumption (VO2), peak workload).

SECONDARY OUTCOMES

walking velocity, walking endurance.

DATA ANALYSIS

The methodological quality was assessed by the PEDro scale. Meta-analyses were performed for all primary and secondary outcomes.

RESULTS

Nine articles (seven RCTs) were identified. The exercise intensity ranged from 50% to 80% heart rate reserve. Exercise duration was 20-40 min for 3-5 days a week. The total number of subjects included in the studies was 480. All studies reported positive effects on aerobic capacity, regardless of the stage of stroke recovery. Meta-analysis revealed a significant homogeneous standardized effect size (SES) in favour of aerobic exercise to improve peak VO2 (SES 0.42; 95% confidence interval (CI) 0.15-0.69; P=0.001) and peak workload (SES 0.50; 95% CI 0.26-0.73; P<0.001). There was also a significant homogeneous SES in favour of aerobic training to improve walking velocity (SES 0.26; 95% CI 0.05-0.48; P= 0.008) and walking endurance (SES 0.30; 95% CI 0.06-0.55; P= 0.008).

CONCLUSIONS

There is good evidence that aerobic exercise is beneficial for improving aerobic capacity in people with mild and moderate stroke. Aerobic exercise should be an important component of stroke rehabilitation.

A randomized controlled trial of supervised versus unsupervised exercise programs for ambulatory stroke survivors

BACKGROUND AND PURPOSE

Little is known about the relative efficacy of supervised versus unsupervised community exercise programs for stroke survivors. This study compared the effectiveness of a 10-week supervised strengthening and conditioning program (supervised) with a 1-week supervised instruction program followed by a 9-week unsupervised home program (unsupervised) and evaluated retention of changes at 6 months and 1 year after program completion.

METHODS

Seventy-two subjects retained at baseline (27 women, 45 men; mean+/-SD age, 64.6+/-11.8 years) were randomly allocated to receive the supervised or unsupervised program. The primary outcome was walking speed over 6 minutes, and secondary outcome measures were Human Activity Profile, Medical Outcome Study 36-Item Short-Form survey (SF-36), Physiological Cost Index, and lower extremity muscle strength.

RESULTS

The 6-minute walking speed increased significantly in both groups and remained significantly improved by 1 year. The Human Activity Profile demonstrated an increasing trend only in the supervised group that was significant by 1 year. The SF-36 Physical Component summary score increased significantly in the supervised group and remained improved by 1 year; the unsupervised group showed significant improvement at 1 year. Women made greater gains in supervised programs, but men made greater gains in unsupervised programs.

CONCLUSIONS

Supervised exercise programs and unsupervised programs after initial supervised instruction were both associated with physical benefits that were retained for 1 year, although supervised programs showed trends to greater improvements in self-reported gains. Gender differences require further research.

Aerobic exercise training in stroke survivors

Functional aerobic capacity among persons with stroke is severely compromised and may limit their full participation in community living. Even though aerobic conditioning can be potentially valuable to persons with stroke in reducing the risk of recurrent morbid events and improving overall quality of life, there is limited information on the specific dose of aerobic exercise (i.e., frequency, intensity, duration, and modality) that may achieve the most desirable health outcomes under the safest conditions in this population. Because of the many comorbidities associated with stroke (i.e., hypertension, heart disease, obesity, depression), specific recommendations for prescribing aerobic exercise must become more precise and be subsequently added to the treatment regimen for this large and diverse population. Future research must address optimal aerobic training programs necessary for reductions in cardiovascular risk factors and gains in functional status in stroke patients.

Exercise-induced changes of the upper extremity in chronic stroke survivors

Problems with daily activities due to decreased aerobic capacity and decreased strength are common in people who survive a stroke. Implementation of exercise for the upper extremity is challenging because of weakness and other impairments that limit performance of exercise activities. Although maximal exercise testing protocols are difficult to administer, submaximal testing may be a safe and effective means for prescribing exercise. Research studies have demonstrated that people with stroke can improve aerobic capacity and upper extremity muscle strength with exercise intervention, although the number of randomized controlled trials is limited and this area requires further investigation.

The impact of physical therapy on functional outcomes after stroke: what's the evidence?

OBJECTIVE

To determine the evidence for physical therapy interventions aimed at improving functional outcome after stroke.

METHODS

MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, PEDro, EMBASE and DocOnline were searched for controlled studies. Physical therapy was divided into 10 intervention categories, which were analysed separately. If statistical pooling (weighted summary effect sizes) was not possible due to lack of comparability between interventions, patient characteristics and measures of outcome, a best-research synthesis was performed. This best-research synthesis was based on methodological quality (PEDro score).

RESULTS

In total, 151 studies were included in this systematic review; 123 were randomized controlled trials (RCTs) and 28 controlled clinical trials (CCTs). Methodological quality of all RCTs had a median of 5 points on the 10-point PEDro scale (range 2-8 points). Based on high-quality RCTs strong evidence was found in favour of task-oriented exercise training to restore balance and gait, and for strengthening the lower paretic limb. Summary effect sizes (SES) for functional outcomes ranged from 0.13 (95% Cl 0.03-0.23) for effects of high intensity of exercise training to 0.92 (95% Cl 0.54-1.29) for improving symmetry when moving from sitting to standing. Strong evidence was also found for therapies that were focused on functional training of the upper limb such as constraint-induced movement therapy (SES 0.46; 95% Cl 0.07-0.91), treadmill training with or without body weight support, respectively 0.70 (95% Cl 0.29-1.10) and 1.09 (95% Cl 0.56-1.61), aerobics (SES 0.39; 95% Cl 0.05-0.74), external auditory rhythms during gait (SES 0.91; 95% Cl 0.40-1.42) and neuromuscular stimulation for glenohumeral subluxation (SES 1.41; 95% Cl 0.76-2.06). No or insufficient evidence in terms of functional outcome was found for: traditional neurological treatment approaches; exercises for the upper limb; biofeedback; functional and neuromuscular electrical stimulation aimed at improving dexterity or gait performance; orthotics and assistive devices; and physical therapy interventions for reducing hemiplegic shoulder pain and hand oedema.

CONCLUSIONS

This review showed small to large effect sizes for task-oriented exercise training, in particular when applied intensively and early after stroke onset. In almost all high-quality RCTs, effects were mainly restricted to tasks directly trained in the exercise programme.