The effect of early aerobic training on independence six months post stroke

Effects of physical therapy modalities for motor function, functional recovery, and post-stroke complications in patients with severe stroke: a systematic review update

BACKGROUND

Physical therapy interventions play a crucial role in the daily care of patients recovering from severe stroke. However, the efficacy of these interventions and associated modalities, including duration, intensity, and frequency, have not been fully elucidated. In 2020, a systematic review reported the beneficial effects of physical therapy for patients with severe stroke but did not assess therapeutic modalities. We aim to update the current evidence on the effects of physical therapy interventions and their modalities in relation to the recovery phase in people with severe stroke in a hospital or inpatient rehabilitation facility.

METHODS

We searched CENTRAL, MEDLINE, Web of Science, and three other relevant databases between December 2018 and March 2021 and updated the search between April 2021 and March 2023.

CLINICALTRIALS

gov and ICTRP for searching trial registries helped to identify ongoing RCTs since 2023. We included individual and cluster randomized controlled trials in the English and German languages that compared physical therapy interventions to similar or other interventions, usual care, or no intervention in a hospital or rehabilitation inpatient setting. We screened the studies from this recent review for eligibility criteria, especially according to the setting. Critical appraisal was performed according to the Cochrane risk-of-bias tool 2.0. The data were synthesized narratively.

RESULTS

The update identified 15 new studies, cumulating in a total of 30 studies (n = 2545 participants) meeting the eligibility criteria. These studies reported 54 outcomes and 20 physical therapy interventions. Two studies included participants during the hyperacute phase, 4 during the acute phase,18 during the early subacute phase, and 3 in the late subacute phase. Three studies started in the chronic phase. Summarised evidence has revealed an uncertain effect of physical therapy on patient outcomes (with moderate to low-quality evidence). Most studies showed a high risk of bias and did not reach the optimal sample size. Little was stated about the standard care and their therapy modalities.

DISCUSSION

There is conflicting evidence for the effectiveness of physical therapy interventions in patients with severe stroke. There is a need for additional high-quality studies that also systematically report therapeutic modalities from a multidimensional perspective in motor stroke recovery. Due to the high risk of bias and the generally small sample size of the included studies, the generalizability of the findings to large and heterogeneous volumes of outcome data is limited.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021244285.

The effects of cycling on walking outcomes in adults with stroke: a systematic review

BACKGROUND

Stationary cycling is often prescribed for survivors of stroke as a safe means of aerobic exercise to improve cardiovascular health. While cycling is typically not prescribed to restore ambulatory function, improvements in measures of walking after cycling interventions have been reported in the literature.

OBJECTIVE

To investigate the effects of cycling on walking outcomes in adults with stroke.

METHODS

Relevant databases were searched through 15 August. Walking-related outcomes were extracted. Correlation coefficients were computed to measure the relationship between exercise protocol parameters and change in walking outcomes.

RESULTS

Eleven articles were included in the review. Eight studies representing nine cycling intervention groups reported change in walking capacity measured by the six-minute walk test with improvements ranging from 6.1 to 63.0 m. Seven studies measured gait velocity, reporting improvements ranging from 0.01 to 0.21 m/sec. Protocols that yielded the greatest improvement in walking capacity prescribed moderate- to high-intensity aerobic training. Significant positive correlations were measured between change in gait velocity and number of exercise sessions and total minutes of exercise prescribed.

CONCLUSION

Considerable heterogeneity was observed across cycling protocols with respect to intensity, frequency, exercise duration and protocol duration. However, none of the studies reported declines in walking outcomes and improvements were measured in the absence of task-specific gait training. Cycling interventions employing moderate- to high-intensity aerobic training and 24 sessions or more may be optimal in improving gait velocity and walking capacity.

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.

Intervention patterns and preliminary effectiveness on Social Participation following stroke: a scoping review

BACKGROUND

Stroke survivors suffer an overall loss of social participation. However, the interventions aiming at improving social participation have not yet been well-established. There is a need to synthesize existing knowledge on clinical interventions aiming at improving social participation among people with stroke.

OBJECTIVE

To describe the patterns of intervention that have been applied to stroke survivors to improve social participation and to determine the preliminary effects of these patterns.

METHODS

Eight online databases, including Cochrane Library, PubMed, Web of Science, Embase, Medline, CINAHL plus, PsycINFO, and Scoups were searched with predefined search terms from inception to September 22, 2022. References of included articles and previous reviews were also checked to identify additional studies. Two reviewers independently selected eligible studies and extracted data from the included articles.

RESULTS

A total of 98 studies were included, of which only 25 studies considered social participation as primary outcome of clinical interventions. The patterns of intervention were various, consisting of exercise-based intervention, occupational therapy, self-management program, and complex intervention. Of the 25 studies, eight studies found a positive effect of relative clinical intervention on social participation for stroke survivors. Of note, the same modality of intervention such as exercise-based intervention and self-management program produced paradoxical conclusion on social participation.

CONCLUSION

Exercised-based intervention, occupational therapy, self-management program, and complex intervention were important intervention modalities for the improvement of social participation among stroke survivors. Even though the preliminary effectiveness on social participation seems to be potentially positive, further high-quality researches are still required to reach a consensus to achieve optimal social participation among stroke survivors.

Effects of aerobic cycling training on mobility and functionality of acute stroke subjects: A randomized clinical trial

BACKGROUND

Studies demonstrate the benefits of aerobic cycling training in subacute and chronic stroke subjects, but there is a lack in the literature about its effects on the acute phase.

OBJECTIVE

Verify the effects of aerobic cycling training on lower limbs muscle strength, gait speed, balance, mobility and functionality of acute stroke subjects.

METHODS

Control group (CG) performed conventional physiotherapy twice a day and the intervention group (IG) performed a conventional physiotherapy and a cycle ergometer session, for five consecutive days. Subjects were assessed for muscle strength by a digital dynamometer, gait speed by the 10-meter-walk-test, balance by the Berg Balance Scale, mobility by the ICU-Mobility-Scale and functionality by the Perme Score.

RESULTS

Twenty subjects were enrolled in the study, 10 in the CG and 10 in the IG. Lower limbs muscle strength, the main endpoint, was better in the IG compared to the CG. The same was found in the secondary endpoints. The intragroup analysis was also positive for the CG in the mobility and functionality.

CONCLUSIONS

Conventional physiotherapy combined with cycling exercise showed better results in the improvement of muscle strength of lower limbs, mobility and functionality of subjects who suffered from acute stroke.

Exercise-based interventions for post-stroke social participation: A systematic review and network meta-analysis

BACKGROUND

Resuming participation in society is an important goal of post-stroke rehabilitation. Exercise-based interventions have been shown to be effective non-pharmacological methods for improving social participation in post-stroke survivors, however it is unclear what the most effective types of exercise interventions are.

OBJECTIVE

To assess the comparative effects and ranks of all exercise-based interventions in improving social participations in patients after a stroke.

METHODS

A random-effects network meta-analysis was performed to identify evidence from relevant randomized control trials. We searched MEDLINE, CINAHL, EMBASE, PsycINFO, CINHAL, Cochrane Library, AMED, SPORTDiscus, Web of Science and Clinical Trials.gov from their earliest records to January 2020. Included trials must include at least one types of exercise for patients with stroke. The primary e was social participation. Bias will be assessed according to the revised Cochrane risk of bias tool. Data were analysed using Stata v14.0. Registration number of this study is CRD42020152523.

RESULTS

A total of 16 randomized control trials involving 1704 patients and 12 intervention arms were included in our study. We performed three subgroup analyses divided based on follow up time (1 to <6 months post-treatment, and ≥6 months post-treatment), and intervention adherence. Based on the ranking probabilities, motor relearning programme was ranked as the most effective among all exercise interventions (surface under cumulative ranking curve values [SUCRCV]: 95.6%, standardized mean difference [SMD]: 2.72, 95% confidence interval [CI]: 1.76 to 3.69) in overall and short-term treatment efficacy. In the long-term subgroup, home-based combined exercise ranked the best for the efficacy of social participation improvements among stroke survivors (SUCRCV: 71.8%, SMD: -0.23, 95% CI: -0.61 to 0.15). In the analysis of all interventions with adherence of >90%, cognitive-based exercise ranked the best (SUCRCV: 100%, SMD: 2.64, 95% CI: 1.62 to 3.66).

CONCLUSIONS

Interventions that emerged with the highest ranks in our analysis might be considered in practice when resources allow. More large, well-designed multicentre trials are needed to support the conclusion of this study.

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.

The effect of rehabilitation interventions on physical function and immobility-related complications in severe stroke: a systematic review

OBJECTIVE

To evaluate the effectiveness of rehabilitation interventions on physical function and immobility-related complications in severe stroke.

DESIGN

Systematic review of electronic databases (Medline, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Physiotherapy Evidence Database, Database of Research in Stroke, Cochrane Central Register of Controlled Trials) searched between January 1987 and November 2018.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement guided the review. Randomised controlled trials comparing the effect of one type of rehabilitation intervention to another intervention, usual care or no intervention on physical function and immobility-related complications for patients with severe stroke were included. Studies that recruited participants with all levels of stroke severity were included only if subgroup analysis based on stroke severity was performed. Two reviewers screened search results, selected studies using predefined selection criteria, extracted data and assessed risk of bias for selected studies using piloted proformas. Marked heterogeneity prevented meta-analysis and a descriptive review was performed. The Grading of Recommendations Assessment, Development and Evaluation approach was used to assess evidence strength.

RESULTS

28 studies (n=2677, mean age 72.7 years, 49.3% males) were included in the review. 24 studies were rated low or very low quality due to high risk of bias and small sample sizes. There was high-quality evidence that very early mobilisation (ie, mobilisation with 24 hours poststroke) and occupational therapy in care homes were no more effective than usual care. There was moderate quality evidence supporting short-term benefits of wrist and finger neuromuscular electrical stimulation in improving wrist extensor and grip strength, additional upper limb training on improving upper limb function and additional lower limb training on improving upper limb function, independence in activities of daily living, gait speed and gait independence.

CONCLUSIONS

There is a paucity of high-quality evidence to support the use of rehabilitation interventions to improve physical function and reduce immobility-related complications after severe stroke. Future research investigating more commonly used rehabilitation interventions, particularly to reduce poststroke complications, is required.

PROSPERO REGISTRATION NUMBER

CRD42017077737.

The Effects of High-Intensity Aerobic Exercise on Cognitive Performance After Stroke: A Pilot Randomised Controlled Trial

Background:

Aerobic exercise is an effective treatment to improve aerobic capacity following stroke and might also improve cognitive impairments in sub-acute stroke survivors. The aim of the study was to assess the effect of high-intensity aerobic exercise on cognitive impairments in sub-acute stroke survivors.

Methods:

A pilot, randomised controlled trial on the effects of aerobic exercise on cognitive impairments of stroke patients in the sub-acute (1-3 months) phase was conducted. Thirty patients with moderate cognitive impairments (maximum score of 5 on at least two items on the cognitive subscales of the Functional Independence Measure [FIM]) were included in the study and randomly assigned to either the intervention group – performing high-intensity aerobic exercise (above 70% of maximum heart rate), or the control group – performing low-intensity aerobic exercise (below 60%). Patients in both groups exercised for 50 min twice a week for 4 weeks. Primary neuropsychological outcome: Trail Making Test B.

Results:

Thirty stroke patients completed the interventions. The results showed that the high-intensity group, compared with the low-intensity group, achieved significant improvements on Trail Making Test B, which assesses processing speed and divided attention (P = .04 after training and P = .01 at follow-up). However, the significant improvements on Trail Making Test B might relate to a ceiling effect in the control group.

Conclusions:

This study does not provide evidence to support that aerobic exercise can improve cognition in stroke survivors, even though significant improvement was revealed on the primary outcome in sub-acute stroke survivors following high-intensity aerobic exercise compared with low-intensity general exercise.

How should long-term free-living physical activity be targeted after stroke? A systematic review and narrative synthesis

BACKGROUND

Increasing physical activity (PA) levels (regular movement such as walking and activities of daily living) and reducing time spent sedentary improves cardiovascular health and reduces morbidity and mortality. Fewer than 30% of independently mobile stroke survivors undertake recommended levels of PA. Sedentary behaviour is also high in this population. We aimed to systematically review the study characteristics and the promise of interventions targeting free-living PA and/or sedentary behaviour in adult stroke survivors.

METHODS

Seven electronic databases were searched to identify randomised controlled trials (≥3-months follow-up) targeting PA and/or sedentary behaviour in adults with first or recurrent stroke or transient ischaemic attack. The quality assessment framework for RCTs was used to assess risk of bias within and across studies. Interventions were rated as "very", "quite" or "non-promising" based on within- or between-group outcome differences. Intervention descriptions were captured using the TIDieR (Template for Intervention Description and Replication) Checklist. Behaviour change techniques (BCTs) within interventions were coded using the BCT Taxonomy v1, and compared between studies by calculating a promise ratio.

RESULTS

Nine studies fulfilled the review criteria (N = 717 randomised stroke patients) with a high or unclear risk of bias. None of the studies targeted sedentary behaviour. Six studies were very/quite promising (reported increases in PA post-intervention). Studies were heterogeneous in their reporting of participant age, time since stroke, stroke type, and stroke location. Sub-optimal intervention descriptions, treatment fidelity and a lack of standardisation of outcome measures were identified. Face to face and telephone-based self-management programmes were identified as having promise to engage stroke survivors in PA behaviour change. Optimal intensity of contact, interventionist type and time after stroke to deliver interventions was unclear. Nine promising BCTs (ratios ≥2) were identified: information about health consequences; information about social and environmental consequences; goal setting-behaviour; problem-solving; action planning; feedback on behaviour; biofeedback; social support unspecified; and credible source.

CONCLUSIONS

Future research would benefit from establishing stroke survivor preferences for mode of delivery, setting and intensity, including measurement of physical activity. Interventions need to justify and utilise a theory/model of behaviour change and explore the optimal combination of promising BCTs within interventions.

Does a cycling program combined with education and followed by coaching promote physical activity in subacute stroke patients? A randomized controlled trial

BACKGROUND

To investigate the effects of a three month active cycling program followed by coaching on physical activity in subacute stroke patients.

METHODS

Patients (n = 59; mean age =65.4 ± 10.3) aged ≤80 years with first stroke and able to cycle at 50 revolutions/minute enrolled 3-10 weeks post stroke. Patients were randomly allocated to three month active cycling group (n = 33) or to a control group (n = 26), 3 x 30 minutes training/week. Afterwards, the active cycling group was randomized into a coaching (n = 15) versus non-coaching group (n = 16) for nine months. Physical activity was measured by objective and self-reported measures, which were taken before/after the active cycling program and during six and 12 months, except the Baecke-questionnaire, which was used at baseline and 12 months.

RESULTS

A significant difference was found in Baecke/sport (95% confidence interval: 0.06, 2.24; p = 0.039) between the active cycling group and the control group, in patients with severe motor function deficits at baseline. Patients in the control group performed significant less sports at 12 months (mean Baecke/sport_baseline =3.07 ± 1.21, mean Baecke/sport_12months = 1.43 ± 0.98; p = 0.01). Furthermore, all groups showed significant changes over time in all measures at three months (except: Physical Activity Scale for Individuals with Physical Disabilities, diary/Mets*minutes-moderate) and 12 month and additionally in a subgroup with severe motor function deficits (except diary Mets*minutes-sedentary).

CONCLUSION

When active cycling combined with education is used in subacute patients with severe motor function deficits, more sport participation might be observed after one year. No other significant group differences were found over time. In all groups, however, patients showed significant improvement over time in physical activity measures. Future work is needed to explore the most effective coaching approach after an aerobic training program. Implications for Rehabilitation The active cycling program combined with education is applicable in subacute stroke patients as it required little stand-by assistance due to chip cards, the intensity was gradually built and the involvement of caregivers in the educational sessions. This training approach also revealed applicable in severely impaired stroke patients and might facilitate sport participation on the long-term. This randomized controlled study aims to quantify physical activity after stroke by using a combination of objective and self-report measures, which revealed detailed information about different aspects of physical activity levels. There is a need for coaching approaches that facilitate aerobic exercise after ending a supervised program. A coaching approach needs to guide patients in adopting aerobic exercise as a part of a lifestyle change and needs to be less time consuming.

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSIONS

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

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

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

Design: Randomized controlled trial.

Setting: Rehabilitation unit.

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

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

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

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

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

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 and to assess the effects of training with regard to adverse events, risk factors, physical fitness, mobility, physical function, quality of life, mood, and cognitive function. Interventions to improve cognitive function have attracted increased attention after being identified as the highest rated research priority for life after stroke. Therefore we have added this class of outcomes to this updated review.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 1: searched February 2015), MEDLINE (1966 to February 2015), EMBASE (1980 to February 2015), CINAHL (1982 to February 2015), SPORTDiscus (1949 to February 2015), and five additional databases (February 2015). 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 (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 58 trials, involving 2797 participants, which comprised cardiorespiratory interventions (28 trials, 1408 participants), resistance interventions (13 trials, 432 participants), and mixed training interventions (17 trials, 957 participants). Thirteen deaths occurred before the end of the intervention and a further nine before the end of follow-up. No dependence data were reported. Diverse outcome measures restricted pooling of data. Global indices of disability show moderate improvement after cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) 0.19 to 0.84; P value = 0.002) and by a small amount after mixed training (SMD 0.26, 95% CI 0.04 to 0.49; P value = 0.02); benefits at follow-up (i.e. after training had stopped) were unclear. There were too few data to assess the effects of resistance training.Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 6.71 metres per minute, 95% CI 2.73 to 10.69), preferred gait speed (MD 4.28 metres per minute, 95% CI 1.71 to 6.84), and walking capacity (MD 30.29 metres in six minutes, 95% CI 16.19 to 44.39) at the end of the intervention. Mixed training, involving walking, increased preferred walking speed (MD 4.54 metres per minute, 95% CI 0.95 to 8.14), and walking capacity (MD 41.60 metres per six minutes, 95% CI 25.25 to 57.95). Balance scores improved slightly after mixed training (SMD 0.27, 95% CI 0.07 to 0.47). Some mobility benefits also persisted at the end of follow-up. The variability, quality of the included trials, and lack of data prevents conclusions about other outcomes and limits generalisability of the observed results.

AUTHORS' CONCLUSIONS

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 the speed and tolerance of walking; some improvement in balance could also occur. There is insufficient evidence to support the use of resistance training. The effects of training on death and dependence after stroke are still unclear but these outcomes are rarely observed in physical fitness training trials. 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 and identify long-term benefits.

The effects of a progressive resistance training program on walking ability in patients after stroke: a pilot study

[Purpose] The purpose of this study was to evaluate the effects of a progressive resistance training (PRT) program on the walking ability of chronic stroke patients with hemiparesis following chronic stroke. [Subjects and Methods] The participants of this study were fifteen hemiplegic patients. The main outcomes measured for this study were the peak torque of the knee extensor; the gait ability as measured by electric gait analysis of walking speed, walking cycle, affected side stance phase, affected side stride length, symmetry index of stance phase, and symmetry index of stride length; and 10-m walking speed; and the Berg balance scale test. [Results] Walking speed and affected side stride length significantly increased after the PRT program, and 10-m walking time significantly decreased after RPT in stroke patients. [Conclusion] These results suggest that the progressive resistance training program may, in part, improve the stride of the affected side leg of stroke patients after stroke and also positively impact walking speed.

Rehabilitation Interventions for Improving Social Participation After Stroke: A Systematic Review and Meta-analysis

BACKGROUND

Despite the fact that social participation is considered a pivotal outcome of a successful recovery after stroke, there has been little attention on the impact of activities and services on this important domain.

OBJECTIVE

To present a systematic review and meta-analysis from randomized controlled trials (RCTs) on the effects of rehabilitation interventions on social participation after stroke.

METHODS

A total of 8 electronic databases were searched for relevant RCTs that evaluated the effects of an intervention on the outcome of social participation after stroke. Reference lists of selected articles were hand searched to identify further relevant studies. The methodological quality of the studies was assessed using the Physiotherapy Evidence Database Scale. Standardized mean differences (SMDs) and confidence intervals (CIs) were estimated using fixed- and random-effect models.

RESULTS

In all, 24 RCTs involving 2042 stroke survivors were identified and reviewed, and 21 were included in the meta-analysis. There was a small beneficial effect of interventions that utilized exercise on social participation (10 studies; SMD = 0.43; 95% CI = 0.09, 0.78;P= .01) immediately after the program ended. Exercise in combination with other interventions (13 studies; SMD = 0.34; 95% CI = 0.10, 0.58;P= .006) also resulted in beneficial effects. No significant effect was observed for interventions that involved support services over 9 studies (SMD = 0.09 [95% CI = -0.04, 0.21];I(2)= 0%;P= .16).

CONCLUSIONS

The included studies provide evidence that rehabilitation interventions may be effective in improving social participation after stroke, especially if exercise is one of the components.

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.

Integrating aerobic training within subacute stroke rehabilitation: a feasibility study

BACKGROUND

Aerobic activity positively affects patients recovering from stroke and is part of best practice guidelines, yet this evidence has not been translated to routine practice.

OBJECTIVE

The objective of this study was to evaluate the feasibility of a model of care that integrated aerobic training in an inpatient rehabilitation setting for patients in the subacute stage of stroke recovery. Key elements of the program were personalized training prescription based on submaximal test results and supervision within a group setting.

DESIGN

This was a prospective cohort study.

METHODS

Participants (N=78) completed submaximal exercise testing prior to enrollment, and the test results were used by their treating physical therapists for exercise prescription. Feasibility was evaluated using enrollment, class attendance, adherence to prescription, and participant perceptions.

RESULTS

Overall, 31 patients (40%) were referred to and completed the exercise program. Cardiac comorbidities were the main reason for nonreferral to the fitness group. Program attendance was 77%; scheduling conflicts were the primary barrier to participation. The majority of participants (63%) achieved 20 minutes of continuous exercise by the end of the program. No adverse events were reported, all participants felt they benefited from the program, and 80% of the participants expressed interest in continuing to exercise regularly after discharge.

LIMITATIONS

Cardiac comorbidities prevented enrollment in the program for 27% of the admitted patients, and strategies for inclusion in exercise programs in this population should be explored.

CONCLUSIONS

This individualized exercise program within a group delivery model was feasible; however, ensuring adequate aerobic targets were met was a challenge, and future work should focus on how best to include individuals with cardiac comorbidities.

The application of cycling and cycling combined with feedback in the rehabilitation of stroke patients: a review

Stroke is a leading cause of long-term disabilities, such as hemiparesis, inability to walk without assistance, and dependence of others in the activities of daily living. Motor function rehabilitation after stroke demands for methods oriented to the recovery of the walking capacity. Because of the similarities with walking, cycling leg exercise may present a solution to this problem. The aim of this article is to review the state of the art applications of cycling leg exercise as a (1) motor function rehabilitation method and an (2) aerobic training method for stroke patients as well as the commonly used (3) assessment tools. The cycling characteristics and applications, the applied test protocols as well as the tools used to assess the state and the recovery of patients and types of cycling devices are presented. In addition, the potential benefits of the use of other therapies, like feedback, together with cycling are explored. The application of cycling leg exercise alone and combined with feedback in stroke rehabilitation approaches has shown promising results. Positive effects on motor abilities were found in subacute and chronic patients. However, larger and normalized studies and assessments are needed because there is a high heterogeneity in the patients' characteristics, protocols and metrics. This wil allow the comparison between different studies related with cycling.

What is the evidence for physical therapy poststroke? A systematic review and meta-analysis

BACKGROUND

Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

METHODS AND FINDINGS

Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N = 25373; median PEDro score 6 [IQR 5-7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03-0.70; I(2) = 0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84-4.11; I(2) = 77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02-0.39; I(2) = 6%) for motor function of the paretic arm to 0.61 (95%CI 0.41-0.82; I(2) = 41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.

CONCLUSIONS

There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.

Effects of substituting a portion of standard physiotherapy time with virtual reality games among community-dwelling stroke survivors

BACKGROUND

Evidence indicates that the continuation of therapy among community-dwelling stroke survivors improves physical function. Community rehabilitation programmes often face limitations in terms of resources. It is imperative to include new motivational interventions to encourage some level of non-clinician management. The aim of this study was to determine whether there were any changes in physical function and activities of daily living when substituting a portion of the standard physiotherapy time with virtual reality games among community-dwelling stroke survivors.

METHODS

In this controlled trial, the experimental group received 30 minutes of virtual reality balance games in addition to 90 minutes of standard physiotherapy. The control group continued with their two hours of routine standard physiotherapy. Both groups received 12 therapy sessions: two-hour sessions twice per week for six continuous weeks. Changes in physical function, activities of daily living and balance ability were assessed using the Timed Up and Go test, 30-second Sit to Stand test, Timed Ten-Metre Walk test, Six-Minute Walk test and the Barthel Index, and static balance was assessed using a probalance board.

RESULTS

Twenty-eight participants completed post-intervention assessments. The results showed a significant within-subject effect on the Timed Up and Go test: F (1, 26) = 5.83, p = 0.02; and the 30-second Sit to Stand test; F (1, 26) = 13.50, p = 0.001. The between-subject effect was not significant (p > 0.05) for any of the outcome measurements.

CONCLUSION

Substituting a portion of the standard physiotherapy time with virtual reality games was equally effective in maintaining physical function outcomes and activities of daily living among community-dwelling stroke survivors.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register, ACTRN12613000478718.

The effects of assisted ergometer training with a functional electrical stimulation on exercise capacity and functional ability in subacute stroke patients

OBJECTIVE

To determine if assistive ergometer training can improve the functional ability and aerobic capacity of subacute stroke patients and if functional electrical stimulation (FES) of the paretic leg during ergometer cycling has additional effects.

METHODS

Sixteen subacute stroke patents were randomly assigned to the FES group (n=8) or the control group (n=8). All patients underwent assistive ergometer training for 30 minutes (five times per week for 4 weeks). The electrical stimulation group received FES of the paretic lower limb muscles during assistive ergometer training. The six-minute walk test (6MWT), Berg Balance Scale (BBS), and the Korean version of Modified Barthel Index (K-MBI) were evaluated at the beginning and end of treatment. Peak oxygen consumption (Vo2peak), metabolic equivalent (MET), resting and maximal heart rate, resting and maximal blood pressure, maximal rate pressure product, submaximal rate pressure product, submaximal rate of perceived exertion, exercise duration, respiratory exchange ratio, and estimated anaerobic threshold (AT) were determined with the exercise tolerance test before and after treatment.

RESULTS

At 4 weeks after treatment, the FES assistive ergometer training group showed significant improvements in 6MWT (p=0.01), BBS (p=0.01), K-MBI (p=0.01), Vo2peak (p=0.02), MET (p=0.02), and estimated AT (p=0.02). The control group showed improvements in only BBS (p=0.01) and K-MBI (p=0.02). However, there was no significant difference in exercise capacity and functional ability between the two groups.

CONCLUSION

This study demonstrated that ergometer training for 4 weeks improved the functional ability of subacute stroke patients. In addition, aerobic capacity was improved after assisted ergometer training with a FES only.

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 January 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12: searched January 2013), MEDLINE (1966 to January 2013), EMBASE (1980 to January 2013), CINAHL (1982 to January 2013), SPORTDiscus (1949 to January 2013), and five additional databases (January 2013). 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 45 trials, involving 2188 participants, which comprised cardiorespiratory (22 trials, 995 participants), resistance (eight trials, 275 participants), and mixed training interventions (15 trials, 918 participants). Nine deaths occurred before the end of the intervention and a further seven at the end of follow-up. No dependence data were reported. Diverse outcome measures made data pooling difficult. Global indices of disability show a tendency to improve after cardiorespiratory training (standardised mean difference (SMD) 0.37, 95% confidence interval (CI) 0.10 to 0.64; P = 0.007); benefits at follow-up and after mixed training were unclear. There were insufficient data to assess the effects of resistance training.Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 7.37 metres per minute, 95% CI 3.70 to 11.03), preferred gait speed (MD 4.63 metres per minute, 95% CI 1.84 to 7.43), walking capacity (MD 26.99 metres per six minutes, 95% CI 9.13 to 44.84), and Berg Balance scores (MD 3.14, 95% CI 0.56 to 5.73) at the end of the intervention. Mixed training, involving walking, increased preferred walking speed (MD 4.54 metres per minute, 95% CI 0.95 to 8.14), walking capacity (MD 41.60 metres per six minutes, 95% CI 25.25 to 57.95), and also pooled balance scores but the evidence is weaker (SMD 0.26 95% CI 0.04 to, 0.49). Some mobility benefits also persisted at the end of follow-up. The variability and trial quality hampered the assessment of the reliability and generalisability of the observed results.

AUTHORS' CONCLUSIONS

The effects of training on death and dependence after stroke are unclear. Cardiorespiratory training reduces disability after stroke and this may be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programs to improve the speed and tolerance of walking; improvement in balance may also occur. There is insufficient evidence to support the use of resistance training. Further well-designed trials are needed to determine the optimal content of the exercise prescription and identify long-term benefits.

Towards more effective robotic gait training for stroke rehabilitation: a review

Background

Stroke is the most common cause of disability in the developed world and can severely degrade walking function. Robot-driven gait therapy can provide assistance to patients during training and offers a number of advantages over other forms of therapy. These potential benefits do not, however, seem to have been fully realised as of yet in clinical practice.

Objectives

This review determines ways in which robot-driven gait technology could be improved in order to achieve better outcomes in gait rehabilitation.

Methods

The literature on gait impairments caused by stroke is reviewed, followed by research detailing the different pathways to recovery. The outcomes of clinical trials investigating robot-driven gait therapy are then examined. Finally, an analysis of the literature focused on the technical features of the robot-based devices is presented. This review thus combines both clinical and technical aspects in order to determine the routes by which robot-driven gait therapy could be further developed.

Conclusions

Active subject participation in robot-driven gait therapy is vital to many of the potential recovery pathways and is therefore an important feature of gait training. Higher levels of subject participation and challenge could be promoted through designs with a high emphasis on robotic transparency and sufficient degrees of freedom to allow other aspects of gait such as balance to be incorporated.

Effects of cardiovascular exercise early after stroke: systematic review and meta-analysis

BACKGROUND

Previous studies have shown the beneficial effects of aerobic exercise in chronic stroke. Most motor and functional recovery occurs in the first months after stroke. Improving cardiovascular capacity may have potential to precipitate recovery during early stroke rehabilitation. Currently, little is known about the effects of early cardiovascular exercise in stroke survivors. The aim of this systematic review was to evaluate the effectiveness of cardiovascular exercise early after stroke.

METHODS

A systematic literature search was performed. For this review, randomized and non-randomized prospective controlled cohort studies using a cardiovascular, cardiopulmonary or aerobic training intervention starting within 6 months post stroke were considered. The PEDro scale was used to detect risk of bias in individual studies. Inter-rater agreement was calculated (kappa). Meta-analysis was performed using a random-effects model.

RESULTS

A total of 11 trials were identified for inclusion. Inter-rater agreement was considered to be "very good" (Kappa: 0.81, Standard Error: 0.06, CI95%: 0.70-0.92), and the methodological quality was "good" (7 studies) to "fair" (4 studies). Peak oxygen uptake data were available for 155 participants. Pooled analysis yielded homogenous effects favouring the intervention group (standardised mean difference (SMD) = 0.83, CI95% = 0.50-1.16, Z = 4.93, P < 0.01). Walking endurance assessed with the 6 Minute Walk Test comprised 278 participants. Pooled analysis revealed homogenous effects favouring the cardiovascular training intervention group (SMD = 0.69, CI95% = 0.45-0.94, Z = 5.58, P < 0.01). Gait speed, measured in 243 participants, did not show significant results (SMD = 0.51, CI95% = -0.25-1.26, Z = 1.31, P = 0.19) in favour of early cardiovascular exercise.

CONCLUSION

This meta-analysis shows that stroke survivors may benefit from cardiovascular exercise during sub-acute stages to improve peak oxygen uptake and walking distance. Thus, cardiovascular exercise should be considered in sub-acute stroke rehabilitation. However, concepts to influence and evaluate aerobic capacity in severely affected individuals with sub-acute stroke, as well as in the very early period after stroke, are lacking.Further research is needed to develop appropriate methods for cardiovascular rehabilitation early after stroke and to evaluate long-term effects of cardiovascular exercise on aerobic capacity, physical functioning, and quality-of-life.

The effect of physical activity on cognitive function after stroke: a systematic review

BACKGROUND

Research in both humans and animals indicates that physical activity can enhance cognitive activity, but whether this is true in patients with stroke is largely unknown.We aimed to evaluate the relationship between increased physical activity after stroke and cognitive performance.

METHODS

A systematic review was conducted of MEDLINE, EMBASE, PsycINFO and other electronic databases. All randomized controlled trials and controlled clinical studies that evaluated the effect of physical activity or exercise on cognitive function in stroke were included. Study quality was assessed using four criteria concerning sources of bias (use of randomization, allocation concealment, blinding of outcome assessment, whether all patients were accounted for in outcome data).

RESULTS

The literature search (first run in 2008, updated in 2011) yielded 12 studies that satisfied inclusion criteria. Exercise interventions were heterogeneous; some studies compared different intensities of movement rehabilitation, others included a specific exercise program. Cognitive function was rarely the primary outcome measure, and cognitive assessment tools used were generally suboptimal. Nine studies had sufficient data to be included in a meta-analysis, which indicated a significant benefit of intervention over control (SMD = 0.20, 95% CI: 0.04–0.36; z = 2.43, p = 0.015). Studies that met all four quality criteria reported smaller treatment benefit than studies that did not.

CONCLUSIONS

There is some evidence that increased physical activity after stroke enhances cognitive performance. The pool of studies identified, however, was small and methodological shortcomings were widespread.

Effects of Lower Limb Reciprocal Pedalling Exercise on Motor Function after Stroke: A Systematic Review of Randomized and Nonrandomized Studies

This review systematically synthesized current evidence on the effects of lower limb reciprocal pedalling exercise on motor function poststroke. Detailed analysis of single studies in the review revealed multiple instances of heterogeneity including outcome measures; therefore we decided to avoid undertaking a single, potentially misleading meta-analysis. We found that despite beneficial (although nondefinitive) effects on balance, functional independence, and muscle strength, it is not possible to make clinical recommendations that support or refute the use of reciprocal pedalling exercise to enhance recovery of motor function after stroke. Our findings provide proof-of-concept for pedalling interventions and provide a foundation for subsequent research, suggesting a need for further standardized, controlled clinical trials of clearly described pedalling interventions for stroke survivors and with subsequent transparent reported findings.

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.

Benefits of wellness interventions for persons with chronic and disabling conditions: a review of the evidence

BACKGROUND

Persons living with the effects of chronic and disabling conditions are often at increased risk for the development of secondary conditions and disabilities that can lead to further decline in health status, independence, functional status, life satisfaction, and overall quality of life.

OBJECTIVE

The purpose of this study was to review the evidence for the benefits of wellness/health promotion interventions for persons with chronic and disabling conditions.

METHODS

The authors conducted a Medline search (1990-2007) using terms related to wellness and health promotion cross-referenced with general terms for chronic and disabling conditions, as well as 15 specific chronic and/or disabling conditions (e.g., multiple sclerosis, spinal cord injury). Selection of studies was limited to those published in English that reported randomized controlled trails or prospective studies that involved adult human subjects with a chronic and/or disabling condition. All selected studies focused on some aspect of a wellness or health promotion intervention and involved a comparison or control group. Of the 5,847 studies initially identified in the search using medical subject heading terms, 190 met the criteria for full review. Data were extracted from these publications and summarized using descriptive statistics.

RESULTS

Almost all studies (95%) explored the effects of wellness intervention in a sample diagnosed with a single condition (e.g., cancer, stroke, arthritis). Although the mean sample size was 100, the range in sample size varied widely (6-688); 25% of the studies had sample of 30 or fewer. Almost all studies (89.5%) reported positive effects of the wellness intervention, although the delivery and content of interventions as well as the measurement of outcomes, varied greatly.

CONCLUSIONS

Our findings support an immediate post-intervention positive impact of wellness interventions across persons with a wide variety of chronic and disabling conditions. Future research that clearly specifies primary study outcomes and follows the CONSORT guidelines will strengthen future reviews of the evidence and facilitate application of the evidence of practice.

Exercise training improves walking function in an African group of stroke survivors: a randomized controlled trial

Objective: To evaluate the effects of treadmill walking and overground walking exercise training on recovery of walking function in an African group of stroke survivors.

Design: Prospective, randomized controlled study.

Setting: Outpatient stroke rehabilitation unit in a tertiary hospital.

Subjects: Sixty patients with chronic stroke (≥3 months).

Intervention: All subjects received individual outpatient conventional physiotherapy rehabilitation for 12 weeks. In addition, subjects in Group A ( n = 20) received treadmill walking exercise training (TWET) while those in Group B ( n = 20) received overground walking exercise training (OWET). Those in Group C (control) ( n = 20) received conventional physiotherapy rehabilitation only.

Main measures: Outcome measures were (i) 10-metre walk time (10MWT) test and (ii) six-minute walk distance (6MWD) test. These were evaluated at entry into the study and at the end of every four weeks. Paired t-tests were used to evaluate the significance of the difference between pre-training and post-training scores on the two measures ( P < 0.05).

Results: Subjects in the TWET group recorded 22.6 ± 1.5% decrease in 10MWT and 31.0 ± 4.3% increase in 6MWD; those in the OWET group made 26.8 ± 1.3% and 45.2 ± 4.6% improvement in 10MWT and 6MWD respectively. Subjects in the control group made 2.2 ± 0.7% and 2.9 ± 0.8% improvement in the two functions. These changes were significant for the TWET and OWET groups ( P < 0.05).

Conclusion: This study indicated that treadmill and overground walking exercise training programmes, combined with conventional rehabilitation, improved walking function in an African group of adult stroke survivors. Therefore, professionals who conduct stroke rehabilitation programmes should utilize exercise training to optimize patient outcomes.

Clinical efficacy and prognostic indicators for lower limb pedalling exercise early after stroke: study protocol for a pilot randomised controlled trial

Background

It is known that repetitive, skilled, functional movement is beneficial in driving functional reorganisation of the brain early after stroke. This study will investigate a) whether pedalling an upright, static exercise cycle, to provide such beneficial activity, will enhance recovery and b) which stroke survivors might be able to participate in pedalling.

Methods/Design

Participants (n = 24) will be up to 30 days since stroke onset, with unilateral weakness and unable to walk without assistance. This study will use a modified exercise bicycle fitted with a UniCam crank. All participants will give informed consent, then undergo baseline measurements, and then attempt to pedal. Those able to pedal will be entered into a single-centre, observer-blinded randomised controlled trial (RCT). All participants will receive routine rehabilitation. The experimental group will, in addition, pedal daily for up to ten minutes, for up to ten working days.

Prognostic indicators, measured at baseline, will be: site of stroke lesion, trunk control, ability to ambulate, and severity of lower limb paresis.

The primary outcome for the RCT is ability to voluntarily contract paretic lower limb muscle, measured by the Motricity Index. Secondary outcomes include ability to ambulate and timing of onset and offset of activity in antagonist muscle groups during pedalling, measured by EMG.

Discussion

This protocol is for a trial of a novel therapy intervention. Findings will establish whether there is sufficient evidence of benefit to justify proceeding with further research into clinical efficacy of upright pedalling exercise early after stroke. Information on potential prognostic indicators will suggest which stroke survivors could benefit from the intervention.

Trial Registration

ISRCTN: ISRCTN45392701

Effects of a high-intensity task-oriented training on gait performance early after stroke: a pilot study

OBJECTIVE

To investigate the feasibility and the effects on gait of a high intensity task-oriented training, incorporating a high cardiovascular workload and large number of repetitions, in patients with subacute stroke, when compared to a low intensity physiotherapy-programme.

DESIGN AND SUBJECTS

Randomized controlled clinical trial: Forty-four patients with stroke were recruited at 2 to 8 weeks after stroke onset.

MEASURES

Maximal gait speed assessed with the 10-metre timed walking test (10MTWT), walking capacity assessed with the six-minute walk test (6MWT). Control of standing balance assessed with the Berg Balance Scale and the Functional Reach test. Group differences were analysed using a Mann-Whitney U-test.

RESULTS

Between-group analysis showed a statistically significant difference in favour of the high intensity task-oriented training in performance on the 10MTWT (Z = -2.13, P = 0.03) and the 6MWT (Z = -2.26, P = 0.02). No between-group difference were found for the Berg Balance Scale (Z = -0.07, P = 0.45) and the Functional Reach test (Z = -0.21, P = 0.84).

CONCLUSION

A high-intensity task-oriented training programme designed to improve hemiplegic gait and physical fitness was feasible in the present study and the effectiveness exceeds a low intensity physiotherapy-programme in terms of gait speed and walking capacity in patients with subacute stroke. In a future study, it seems appropriate to additionally use measures to evaluate physical fitness and energy expenditure while walking.

Physical exercise and cognitive recovery in acquired brain injury: a review of the literature

OBJECTIVE

Physical exercise has been shown to play an ever-broadening role in the maintenance of overall health and has been implicated in the preservation of cognitive function in both healthy elderly and demented populations. Animal and human studies of acquired brain injury (ABI) from trauma or vascular causes also suggest a possible role for physical exercise in enhancing cognitive recovery.

DATA SOURCES

A review of the literature was conducted to explore the current understanding of how physical exercise impacts the molecular, functional, and neuroanatomic status of both intact and brain-injured animals and humans.

STUDY SELECTION

Searches of the MEDLINE, CINHAL, and PsychInfo databases yielded an extensive collection of animal studies of physical exercise in ABI. Animal studies strongly tie physical exercise to the upregulation of multiple neural growth factor pathways in brain-injured animals, resulting in both hippocampal neurogenesis and functional improvements in memory.

DATA EXTRACTION

A search of the same databases for publications involving physical exercise in human subjects with ABI yielded 24 prospective and retrospective studies.

DATA SYNTHESIS

Four of these evaluated cognitive outcomes in persons with ABI who were involved in physical exercise. Three studies cited a positive association between exercise and improvements in cognitive function, whereas one observed no effect. Human exercise interventions varied greatly in duration, intensity, and level of subject supervision, and tools for assessing neurocognitive changes were inconsistent.

CONCLUSIONS

There is strong evidence in animal ABI models that physical exercise facilitates neurocognitive recovery. Physical exercise interventions are safe in the subacute and rehabilitative phases of recovery for humans with ABI. In light of strong evidence of positive effects in animal studies, more controlled, prospective human interventions are warranted to better explore the neurocognitive effects of physical exercise on persons with ABI.

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.

Motor recovery after stroke: a systematic review

Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. In this Review, we aimed to provide an overview of the available evidence on interventions for motor recovery after stroke through the evaluation of systematic reviews, supplemented by recent randomised controlled trials. Most trials were small and had some design limitations. Improvements in recovery of arm function were seen for constraint-induced movement therapy, electromyographic biofeedback, mental practice with motor imagery, and robotics. Improvements in transfer ability or balance were seen with repetitive task training, biofeedback, and training with a moving platform. Physical fitness training, high-intensity therapy (usually physiotherapy), and repetitive task training improved walking speed. Although the existing evidence is limited by poor trial designs, some treatments do show promise for improving motor recovery, particularly those that have focused on high-intensity and repetitive task-specific practice.

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.

Task-oriented training in rehabilitation after stroke: systematic review

AIM

This paper is a report of a review conducted to provide an overview of the evidence in the literature on task-oriented training of stroke survivors and its relevance in daily nursing practice.

BACKGROUND

Stroke is the second leading cause of death and one of the leading causes of adult disability in the Western world. The use of neurodevelopmental treatment in the daily nursing care of stroke survivors does not improve clinical outcomes. Nurses are therefore exploring other forms of rehabilitation intervention, including task-oriented rehabilitation. Despite the growing number of studies showing evidence on task-oriented interventions, recommendations for daily nursing practice are lacking.

DATA SOURCES

A range of databases was searched to identify papers addressing task-oriented training in stroke rehabilitation, including Medline, CINAHL, Embase and the Cochrane Library of systematic reviews. Papers published in English between January 1996 and September 2007 were included. There were 42 papers in the final dataset, including nine systematic reviews.

REVIEW METHODS

The selected randomized controlled trials and systematic reviews were assessed for quality. Important characteristics and outcomes were extracted and summarized.

RESULTS

Studies of task-related training showed benefits for functional outcome compared with traditional therapies. Active use of task-oriented training with stroke survivors will lead to improvements in functional outcomes and overall health-related quality of life.

CONCLUSION

Generally, task-oriented rehabilitation proved to be more effective. Many interventions are feasible for nurses and can be performed in a ward or at home. Nurses can and should play an important role in creating opportunities to practise meaningful functional tasks outside of regular therapy sessions.

Effects of Exercise Training Programs on Walking Competency After Stroke

To determine the effectiveness of training programs that focus on lower-limb strengthening, cardiorespiratory fitness, or gait-oriented tasks in improving gait, gait-related activities, and health-related quality of life after stroke. Randomized controlled trials (RCTs) were searched for in the databases of Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, Physiotherapy Evidence Database (PEDro), EMBASE, Database of the Dutch Institute of Allied Health Care, and CINAHL. Databases were systematically searched by two independent researchers. The following inclusion criteria were applied: (1) participants were people with stroke, older than 18 yrs; (2) one of the outcomes focused on gait-related activities; (3) the studies evaluated the effectiveness of therapy programs focusing on lower-limb strengthening, cardiorespiratory fitness, or gait-oriented training; and (4) the study was published in English, German, or Dutch. Studies were collected up to November 2005, and their methodological quality was assessed using the PEDro scale. Studies were pooled and summarized effect sizes were calculated. Best-evidence synthesis was applied if pooling was impossible. Twenty-one RCTs were included, of which five focused on lower-limb strengthening, two on cardiorespiratory fitness training (e.g., cycling exercises), and 14 on gait-oriented training. Median PEDro score was 7. Meta-analysis showed a significant medium effect of gait-oriented training interventions on both gait speed and walking distance, whereas a small, nonsignificant effect size was found on balance. Cardiorespiratory fitness programs had a nonsignificant medium effect size on gait speed. No significant effects were found for programs targeting lower-limb strengthening. In the best-evidence synthesis, strong evidence was found to support cardiorespiratory training for stair-climbing performance. Although functional mobility was positively affected, no evidence was found that activities of daily living, instrumental activities of daily living, or health-related quality of life were significantly affected by gait-oriented training. This review shows that gait-oriented training is effective in improving walking competency after stroke.

Exercise rehabilitation after stroke

Stroke is a leading cause of disability that results not only in persistent neurological deficits, but also profound physical deconditioning that propagates disability and worsens cardiovascular risk. The potential for exercise-mediated adaptations to improve function, fitness, and cardiovascular health after stroke has been underestimated: it represents an emerging arena in neurotherapeutics. To define the health rationale for cardiovascular (aerobic) exercise, we first outline the impact of debilitating secondary biological changes in muscle and body composition on fitness and metabolic health after stroke. We provide an overview of evidence-based advances in exercise therapeutics, with a focus on task-oriented models that combine a progressive aerobic conditioning stimulus with motor learning to improve multiple physiological domains that determine longitudinal outcomes after stroke. Although progress in development of safe and effective exercise strategies is advancing, fundamental questions regarding dose intensity, prescription to optimize central and peripheral neuromuscular adaptations, and the public health value of exercise in secondary stroke prevention remain unanswered. Key issues steering future research in exercise neurotherapeutics are discussed within the context of initiatives to facilitate translation to community-based studies, requisite for dissemination.