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

Oxygen Consumption and Metabolic Equivalents During Physical Activities in Stroke: A Systematic Review

BACKGROUND AND PURPOSE

Patient education on physical activity (PA) requires a clear understanding of PA intensity. However, there is no organized list of PAs intensities specific to individuals with stroke. This review aimed to clarify the intensity of PAs in people with stroke and summarize the methodologies and participant characteristics in previous investigations of energy expenditure (EE) during PAs.

METHODS

A systematic search was conducted using PubMed, CINAHL, the Cochrane Library, and PEDro databases in October 2021, and repeated in February 2024. Reports meeting the eligibility criteria were reviewed to extract participant characteristics and summarized EE for each PA type according to gait ability. Where possible, EE during PA was integrated using a weighted mean.

RESULTS

A total of 55 eligible articles and 1719 participants were included. Twenty-one PAs were identified, most of which involved walking or exercise. Data on acute stroke were sparse, accounting for only 1.2% of all participants. PAs related to daily living were typically measured over 5-8 min, with steady-state means used for movement tasks. Among ambulatory patients, walking with maximal effort corresponded to moderate-to-vigorous PA (> 3 METs), even at low speeds. However, comfortable walking at slow speeds, sit-to-stand, and reaching while standing corresponded to light PA (1.6-2.9 METs).

DISCUSSION

EE during PA in people with stroke has been inadequately investigated, particularly for daily activities other than walking, and studies involving acute stroke remain limited. Additionally, EE during light PAs, such as reaching, sit-to-stand, wheelchair propulsion, and comfortable walking at slow speed in ambulatory stroke patients, was found to align closely with values reported in the Compendium of PAs.

TRIAL REGISTRATION

PROSPERO, CRD42022300366.

Current exercise-based rehabilitation impacts on poststroke exercise capacity, blood pressure, and lipid control: a meta-analysis

Objectives

This systematic review aimed to evaluate the impact of post-stroke exercise-based rehabilitation programs on blood pressure, lipid profile, and exercise capacity.

Methods

Through a systemic search of literature from inception to 2024 using five databases, we analyzed data on the mean difference (MD) using a meta-analysis method to estimate effectiveness.

Results

Thirty-seven randomized control trials were included encompassing various exercises such as aerobic, resistance, stretching, exergaming, robot-assisted training, and community-based training. Significant improvement was illustrated at discharge in systolic [MD 2.76 mmHg; 95% confidence interval (CI) -1.58 to 3.92, P < 0.05] and diastolic (MD 1.28 mmHg; 95% CI 0.54-2.12, P < 0.05) blood pressure and peak oxygen volume (MD -0.29 ml/kg/min; 95% CI -0.53 to 0.05, P < 0.05). We also observed significant improvement at discharge in high-density lipoprotein only after resistance exercise from two articles and low-density lipoprotein only in the intervention groups compared to the control groups from ten articles.

Conclusion

Overall, current exercise-based rehabilitation programs significantly improve blood pressure and exercise capacity in patients with stroke at discharge. However, lipoprotein changes remained inconclusive. Although ameliorative changes were noted in most variables, more research is needed to determine optimum exercise intensity, type combination, and health education to reduce post-stroke complications and mortality.

Systematic Review Registration

https://doi.org/10.17605/OSF.IO/X89FW.

Personalized heart rate management through data-driven dynamic exercise control

Maximizing healthy life expectancy is essential for enhancing well-being. Optimal exercise intensity is crucial in promoting health and ensuring safe rehabilitation. Since heart rate is related to exercise intensity, the required exercise intensity is achieved by controlling the heart rate. This study aims to control heart rate during exercise by dynamically adjusting the load on a bicycle ergometer using a proportional-integral (PI) control. The choice of PI parameters is very important because the PI parameters significantly affect the performance of heart rate control. Since the dynamic characteristics of heart rate relative to work rate vary widely from subject to subject, the PI parameters for each subject must be determined individually. In this study, PI parameters are optimized directly from exercise data using a data-driven design approach. Thus, the proposed method does not require excessive exercise of the subject to model heart rate dynamics. Using the proposed method, the heart rate can be controlled to follow a designed reference model so that the heart rate is safely increased to the desired value. The quantitative evaluation of the control results of fifteen healthy volunteers confirmed that the proposed method improved the control error of the target heart rate trajectory by approximately 40%, regardless of gender or age. In addition, it was shown that control parameters from the exercise experiment also indicate that females are more likely than males to have an elevated heart rate at the same load.

Robot-assisted support combined with electrical stimulation for the lower extremity in stroke patients: a systematic review

Objective. The incidence of stroke rising, leading to an increased demand for rehabilitation services. Literature has consistently shown that early and intensive rehabilitation is beneficial for stroke patients. Robot-assisted devices have been extensively studied in this context, as they have the potential to increase the frequency of therapy sessions and thereby the intensity. Robot-assisted systems can be combined with electrical stimulation (ES) to further enhance muscle activation and patient compliance. The objective of this study was to review the effectiveness of ES combined with all types of robot-assisted technology for lower extremity rehabilitation in stroke patients.Approach. A thorough search of peer-reviewed articles was conducted. The quality of the included studies was assessed using a modified version of the Downs and Black checklist. Relevant information regarding the interventions, devices, study populations, and more was extracted from the selected articles.Main results. A total of 26 articles were included in the review, with 23 of them scoring at least fair on the methodological quality. The analyzed devices could be categorized into two main groups: cycling combined with ES and robots combined with ES. Overall, all the studies demonstrated improvements in body function and structure, as well as activity level, as per the International Classification of Functioning, Disability, and Health model. Half of the studies in this review showed superiority of training with the combination of robot and ES over robot training alone or over conventional treatment.Significance. The combination of robot-assisted technology with ES is gaining increasing interest in stroke rehabilitation. However, the studies identified in this review present challenges in terms of comparability due to variations in outcome measures and intervention protocols. Future research should focus on actively involving and engaging patients in executing movements and strive for standardization in outcome values and intervention protocols.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

DATA ANALYSIS

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

RESULTS

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

CONCLUSIONS

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

Cycling using functional electrical stimulation therapy to improve motor function and activity in post-stroke individuals in early subacute phase: a systematic review with meta-analysis

BACKGROUND

Stroke necessitates interventions to rehabilitate individuals with disabilities, and the application of functional electrical stimulation therapy (FEST) has demonstrated potential in this regard. This study aimed to analyze the efficacy and effectiveness of cycling using FEST to improve motor function and lower limb activity in post-stroke individuals.

METHODS

We performed a systematic review according to the recommendations of the PRISMA checklist, searching MEDLINE, Cochrane, EMBASE, LILACS, and PEDro databases by July 2022, without any date or language limitations. Studies were selected using the following terms: stroke, electrical stimulation therapy, cycling, and clinical trials. Randomized or quasi-randomized clinical trials that investigated the effectiveness of cycling using FEST combined with exercise programs and cycling using FEST alone for motor function and activity in subacute post-stroke individuals were included. The quality of included trials was assessed using the PEDro scores. Outcome data were extracted from eligible studies and combined in random-effects meta-analyses. The quality of evidence was determined according to the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

Five randomized clinical trials involving 187 participants were included. Moderate-quality evidence indicates that cycling using FEST combined with exercise programs promotes relevant benefits in trunk control (MD 9 points, 95% CI 0.36-17.64) and walking distance (MD 94.84 m, 95% CI 39.63-150.05, I = 0%), the other outcomes had similar benefits. Cycling using FEST alone compared to exercise programs promotes similar benefits in strength, balance, walking speed, walking distance, and activities of daily living.

CONCLUSION

This systematic review provides low- to moderate-quality evidence that cycling using FEST may be an effective strategy to consider in improving motor function and activity outcomes for post-stroke individuals in the early subacute phase.

REVIEW REGISTRATION

PROSPERO (CRD42022345282).

Effect of Cycling Exercise Resisting Electrically Stimulated Antagonist Muscle Contractions in Healthy Males

A hybrid training system (HTS) combining antagonist muscle electrical stimulation and voluntary muscle contraction has been developed using eccentric antagonist muscle contractions with electrical stimulation as resistance to voluntary muscle contractions. We devised an exercise method using HTS combined with a cycle ergometer (HCE). The purpose of this study was to compare the muscle strength, muscle volume, aerobic functions and lactate metabolism of HCE and a volitional cycle ergometer (VCE). A total of 14 male participants performed exercise on a bicycle ergometer for 30 min per session, 3 times per week for 6 weeks. We divided 14 participants into an HCE group (7 participants) and a VCE group (7 participants). The workload was set at 40% of each participant's peak oxygen uptake (V.O₂peak). Electrodes were placed over each motor point on the quadriceps and hamstrings. The V.O₂peak and anaerobic threshold significantly increased before and after training when using HCE rather than VCE. The HCE group had significantly increased extension and flexion muscle strength at 180 degrees/s in post-training measurements over pre-training measurements. Knee flexion muscle strength at 180 degrees/s tended to increase in the HCE group compared to the VCE group. The quadricep muscle cross-sectional area was significantly increased in the HCE group compared to the VCE group. Additionally, the HCE group had significantly decreased maximal lactate, measured every 5 min during exercise at the end of study, between pre and post-training. Thus, HCE may be a more effective training method for muscle strength, muscle mass and aerobic functions at 40% of each participant's V.O₂peak than conventional cycling exercise. HCE could be applied not only as aerobic exercise but also as resistance training.

Muscle Electrical Impedance Properties and Activation Alteration After Functional Electrical Stimulation-Assisted Cycling Training for Chronic Stroke Survivors: A Longitudinal Pilot Study

Electrical impedance myography (EIM) is a sensitive assessment for neuromuscular diseases to detect muscle inherent properties, whereas surface electromyography (sEMG) is a common technique for monitoring muscle activation. However, the application of EIM in detecting training effects on stroke survivors is relatively few. This study aimed to evaluate the muscle inherent properties and muscle activation alteration after functional electrical stimulation (FES)-assisted cycling training to chronic stroke survivors. Fifteen people with chronic stroke were recruited for 20 sessions of FES-assisted cycling training (40 min/session, 3–5 sessions/week). The periodically stimulated and assessed muscle groups were quadriceps (QC), tibialis anterior (TA), hamstrings (HS), and medial head of gastrocnemius (MG) on the paretic lower extremity. EIM parameters [resistance (R), reactance (X), phase angle (θ), and anisotropy ratio (AR)], clinical scales (Fugl-Meyer Lower Extremity (FMA-LE), Berg Balance Scale (BBS), and 6-min walking test (6MWT)] and sEMG parameters [including root-mean square (RMS) and co-contraction index (CI) value] were collected and computed before and after the training. Linear correlation analysis was conducted between EIM and clinical scales as well as between sEMG and clinical scales. The results showed that motor function of the lower extremity, balance, and walking performance of subjects improved after the training. After training, θ value of TA (P = 0.014) and MG (P = 0.017) significantly increased, and AR of X (P = 0.004) value and AR of θ value (P = 0.041) significantly increased on TA. The RMS value of TA decreased (P = 0.022) and a significant reduction of CI was revealed on TA/MG muscle pair (P < 0.001). Significant correlation was found between EIM and clinical assessments (AR of X value of TA and FMA-LE: r = 0.54, P = 0.046; X value of TA and BBS score: 0.628, P = 0.016), and between sEMG and clinical scores (RMS of TA and BBS score: r = −0.582, P = 0.029). This study demonstrated that FES-assisted cycling training improved lower limb function by developing coordinated muscle activation and facilitating an orderly myofiber arrangement. The current study also indicated that EIM can jointly evaluate lower extremity function alteration with sEMG after rehabilitation training.

Clinical Trail Registration: The study was registered on the Clinical Trial Registry (trial registration number: NCT 03208439, https://clinicaltrials.gov/ct2/show/NCT03208439).

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

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

Metabolic, ventilatory and cardiovascular responses to FES-cycling: A comparison to NMES and passive cycling

BACKGROUND

Cyclergometry with functional electrical stimulation (FES-cycling) is a feasible method for rehabilitation. The concept is to promote exercise induced by depolarization of the motoneuron and muscular contraction.

OBJECTIVE

To measure acute physiological responses to FES-cycling.

METHODS

Retrospective study of data from ten healthy volunteers who performed FES-cycling, passive cycling and neuromuscular electrical stimulation (NMES) alone. Metabolic, ventilatory and cardiovascular parameters were analyzed.

RESULTS

Oxygen uptake enhanced 97 ± 15% during FES-cycling, with medium effect size compared to NMES and large effect size compared to passive cycling. Energy expenditure enhanced 102 ± 15% during FES-cycling, with medium effect size compared to NMES and large effect size compared to passive cycling. Minute ventilation enhanced 115 ± 26% during FES-cycling, with small effect size compared to NMES and medium effect size compared to passive cycling. Cardiac output enhanced 21 ± 4% during FES-cycling, with medium effect size compared to NMES and passive cycling. Arterial - mixed venous oxygen content difference enhanced 60 ± 8% during FES-cycling, with a medium effect size compared to NMES and large effect size compared to passive cycling.

CONCLUSIONS

FES-cycling enhances metabolic, ventilatory and cardiovascular demands and the physiological responses are higher than NMES and passive cycling.

Effects of Inspiratory Muscle Training on Respiratory Muscle Strength, Trunk Control, Balance and Functional Capacity in Stroke Patients: A single-blinded randomized controlled study

Objective: Aim of the study was to examine the effects of inspiratory muscle training (IMT) on respiratory function, respiratory muscle strength, trunk control, balance, and functional capacity in stroke patients.Methods: 21 stroke individuals were randomly divided into two groups as control group and treatment group. Respiratory function test, Maximal Inspiratory Pressure (MIP) and Maximal Expiratory Pressure (MEP) were evaluated. Also, Trunk Impairment Scale (TIS), Timed Up and Go Test (TUG) Berg Balance Scale (BBS), and Six-Minute Walk Test (6MWT) were performed. Neurodevelopmental treatment program was performed in both groups for 5 days a week for 6 weeks, and IMT was given to the treatment group. IMT was started from 40% of MIP.Results: After treatment, respiratory functions, respiratory muscle strength, and trunk control and balance improved in the treatment group. In the control group; however, only the balance level was improved. When the changes in the evaluation parameters between the groups were compared, there were only statistically significant differences in the TIS, Peak Expiratory Flow (PEF) and MIP in the treatment group (p˂0.05), the change amounts in other evaluation parameters were similar (p˃0.05). When the effect size of the groups was compared, the effect size of the variables in the treatment group was found to be higher.Conclusions: As a conclusion, IMT, which was given in addition to the neurological physiotherapy and rehabilitation program to our patients, improved inspiratory muscle strength and trunk control. We believe that this result will raise awareness for physiotherapists working in the field of neurological rehabilitation about including respiratory muscle training in the rehabilitation program of stroke patients.

Functional Electrical Stimulation Therapy for Retraining Reaching and Grasping After Spinal Cord Injury and Stroke

Neurological conditions like hemiplegia following stroke or tetraplegia following spinal cord injury, result in a massive compromise in motor function. Each of the two conditions can leave individuals dependent on caregivers for the rest of their lives. Once medically stable, rehabilitation is the main stay of treatment. This article will address rehabilitation of upper extremity function. It is long known that moving the affected limb is crucial to recovery following any kind of injury. Overtime, it has also been established that just moving the affected extremities does not suffice, and that the movements have to involve patient’s participation, be as close to physiologic movements as possible, and should ideally stimulate the entire neuromuscular circuitry involved in producing the desired movement. For over four decades now, functional electrical stimulation (FES) is being used to either replace or retrain function. The FES therapy discussed in this article has been used to retrain upper extremity function for over 15 years. Published data of pilot studies and randomized control trials show that FES therapy produces significant changes in arm and hand function. There are specific principles of the FES therapy as applied in our studies: (i) stimulation is applied using surface stimulation electrodes, (ii) there is minimum to virtually no pain during application, (iii) each session lasts no more than 45–60 min, (iv) the technology is quite robust and can make up for specificity to a certain extent, and (v) fine motor function like two finger precision grip can be trained (i.e., thumb and index finger tip to tip pinch). The FES therapy protocols can be successfully applied to individuals with paralysis resulting from stroke or spinal cord injury.

Does cycling induced by functional electrical stimulation enhance motor recovery in the subacute phase after stroke? A systematic review and meta-analysis

OBJECTIVE

To investigate the effects of cycling with functional electrical stimulation on walking, muscle power and tone, balance and activities of daily living in subacute stroke survivors.

DATA SOURCES

Ten electronic databases were searched from inception to February 2020.

REVIEW METHODS

Inclusion criteria were: subacute stroke survivors (<6 months since stroke), an experimental group performing any type of cycling training with electrical stimulation, alone or in addition to usual care, and a control group performing usual care alone. Two reviewers assessed eligibility, extracted data and analyzed the risks of bias. Standardized Mean Difference (SMD) or Mean Difference (MD) with 95% Confidence Intervals (CI) were estimated using fixed- or random-effects models to evaluate the training effect.

RESULTS

Seven randomized controlled trials recruiting a total of 273 stroke survivors were included in the meta-analyses. There was a statistically significant, but not clinically relevant, effect of cycling with electrical stimulation compared to usual care on walking (six studies, SMD [95% CI] = 0.40 [0.13, 0.67]; P = 0.004), capability to maintain a sitting position (three studies, MD [95% CI] = 7.92 [1.01, 14.82]; P = 0.02) and work produced by the paretic leg during pedaling (2 studies, MD [95% CI] = 8.13 [1.03, 15.25]; P = 0.02). No significant between-group differences were found for muscular power, tone, standing balance, and activities of daily living.

CONCLUSIONS

Cycling training with functional electrical stimulation cannot be recommended in terms of being better than usual care in subacute stroke survivors. Further investigations are required to confirm these results, to determine the optimal training parameters and to evaluate long-term effects.

Electrical Stimulation in Lower Limb During Exercise to Improve Gait Speed and Functional Motor Ability 6 Months Poststroke. A Review with Meta-Analysis

INTRODUCTION

Stroke is the third most common cause of disability in adults over 65 years of age and there are 30.7 million survivors after stroke worldwide. Stroke survivors have the highest odds of reporting severe disability and the greatest variety of individual domains of disability compared to a range of other conditions. Electrical stimulation of peripheral sensory-motor systems increases voluntary movement and muscle strength and thereby raises the activities of daily living (ADL). Little is known about electrical stimulation during physical activity in rehabilitation; the objective of this review is therefore to investigate whether external electrical stimulation combined with activity improves functional motor ability and gait speed in patients who have experienced a stroke within the last 6 months.

METHODS

A review and random effects meta-analysis of randomized controlled clinical trials on gait speed and functional motor ability measured with Barthel Index (BI) and Bergs Balance Scale (BBS).

RESULTS

Eight trials were included (n = 191). Explorative meta-analysis was performed on gait speed (5 trials, n = 120), BI (3 trials, n = 74), and BBS (3 trial n = 79). A small, significant difference on gait speed 0.15 (95% confidence interval [CI]: 0.08-0.21) m/s, but no difference in BI 2.88 (95 % CI: -3.3 to 9.07) and BBS 1.73 (95% CI: -2.8 to 6.27).

CONCLUSIONS

Sparse, low-quality evidence indicates that electrical stimulation combined with activity is a relevant intervention to improve ADL within 6 months poststroke.

A multimodal training with visual biofeedback in subacute stroke survivors: a randomized controlled trial

BACKGROUND

Early interventions maximizing patient's involvement are essential to promote gait restoration and motor recovery after stroke.

AIM

The aim of this study is to evaluate the effects of a multimodal biofeedback training involving cycling augmented by functional electrical stimulation (FES) and balance exercises on walking ability and motor recovery.

DESIGN

Randomized controlled trial (NCT02439515).

SETTING

Inpatient rehabilitation facility.

POPULATION

Subacute stroke survivors (less than 6 months from the first event) aged up to 90 years old.

METHODS

Sixty-eight participants were randomly allocated to an experimental group, performing 15 sessions of biofeedback FES-cycling training followed by 15 sessions of biofeedback balance training (20 minutes each) in addition to usual care (70 minutes), and a control group performing 30 sessions (90 minutes) of usual care. Participants were evaluated before training, after 15 sessions, after 30 sessions, and at 6-month follow-up through: gait speed (primary outcome), spatiotemporal gait parameters, Six-Minute Walking Test, Functional Independence Measure, Motricity Index, Trunk Control Test, Berg Balance Scale, and Fall Efficacy Scale.

RESULTS

Both groups significantly improved over time, but no group and interaction effects were found for any outcomes. The 73% of the experimental group achieved a clinically meaningful change in gait speed compared to the 38% of the control group (P=0.048). These percentages were even more unbalanced for patients with a moderate to severe gait impairment at baseline (91% versus 36%; P=0.008).

CONCLUSIONS

The multimodal biofeedback training was not statistically superior to usual care, showing only a positive trend in favor of the experimental group on locomotion recovery. Patients initially not able to walk might be the best candidates for such a training.

CLINICAL REHABILITATION IMPACT

The multimodal biofeedback training is a task-specific, repetitive and intensive training requiring a minimal supervision, which might result in a lower staff to patient ratio if organized in group sessions. Therefore, it can represent a good alternative for early stroke rehabilitation.

The effects of cycling with and without functional electrical stimulation on lower limb dysfunction in patients post-stroke: A systematic review with meta-analysis

BACKGROUND

One of the leading causes of disability in the world with enormous economic burden is stroke.

OBJECTIVE

To quantify the effectiveness of different protocols of cycling with/without functional electrical stimulation on functional mobility after stroke.

METHODS

Multiple databases were searched till 2018. Data extraction was performed using a pre-determined data collection form. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

A total of 14 trials satisfied eligibility criteria and were included. Cycling had a positive effect on the 6-meter walking test performance (SMD, 0.41; 95% CI, 0.11 -0.71; I2 = 0% ) compared with no or placebo intervention (control). Compared with control, cycling had a positive effect on 10-meter walking speed (SMD, 0.30; 95% CI, 0.05 -0.55; I2 = 0% ), and on balance based on the Berg score (SMD, 0.32; 95% CI, 0.06 -0.57; I2 = 49% ). Cycling with functional electrical stimulation had a positive effect on balance (SMD, 1.48; 95% CI, 0.99 -1.97; I2 = 91% ) compared with cycling alone.

CONCLUSIONS

It appears that cycling has a positive effect on walking speed, walking ability and balance. Functional electrical stimulation combined with cycling has positive effects on balance beyond cycling alone.

Novel multi-pad functional electrical stimulation in stroke patients: A single-blind randomized study

BACKGROUND

Foot drop is common gait impairment after stroke. Functional electrical stimulation (FES) of the ankle dorsiflexor muscles during the swing phase of gait can help correcting foot drop.

OBJECTIVE

To evaluate efficacy of additional novel FES system to conventional therapy in facilitating motor recovery in the lower extremities and improving walking ability after stroke.

METHODS

Sixteen stroke patients were randomly allocated to the FES group (FES therapy plus conventional rehabilitation program) (n = 8), and control group (conventional rehabilitation program) n = 8. FES was delivered for 30 min during gait to induce ankle plantar and dorsiflexion.

MAIN OUTCOME MEASURES

gait speed using 10 Meter Walk Test (10 MWT), Fugl-Meyer Assessment (FMA), Berg Balance Scale (BBS) and modified Barthel Index (MBI).

RESULTS

Results showed a significant increase in gait speed in FES group (p < 0.001), higher than the minimal detected change. The FES group showed improvement in functional independence in the activities of daily living, motor recovery and gait performance.

CONCLUSIONS

The findings suggest that novel FES therapy combined with conventional rehabilitation is more effective on walking speed, mobility of the lower extremity, balance disability and activities of daily living compared to a conventional rehabilitation program only.

Factors Influencing the Efficacy of Aerobic Exercise for Improving Fitness and Walking Capacity After Stroke: A Meta-Analysis With Meta-Regression

OBJECTIVE

To assess the influence of dosing parameters and patient characteristics on the efficacy of aerobic exercise (AEX) poststroke.

DATA SOURCES

A systematic review was conducted using PubMed, MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Physiotherapy Evidence Database, and Academic Search Complete.

STUDY SELECTION

Studies were selected that compared an AEX group with a nonaerobic control group among ambulatory persons with stroke.

DATA EXTRACTION

Extracted outcome data included peak oxygen consumption (V˙o₂peak) during exercise testing, walking speed, and walking endurance (6-min walk test). Independent variables of interest were AEX mode (seated or walking), AEX intensity (moderate or vigorous), AEX volume (total hours), stroke chronicity, and baseline outcome scores.

DATA SYNTHESIS

Significant between-study heterogeneity was confirmed for all outcomes. Pooled AEX effect size estimates (AEX group change minus control group change) from random effects models were V˙o₂peak, 2.2mL⋅kg^-1⋅min^-1 (95% confidence interval [CI], 1.3-3.1mL⋅kg^-1⋅min^-1); walking speed, .06m/s (95% CI, .01-.11m/s); and 6-minute walk test distance, 29m (95% CI, 15-42m). In meta-regression, larger V˙o₂peak effect sizes were significantly associated with higher AEX intensity and higher baseline V˙o₂peak. Larger effect sizes for walking speed and the 6-minute walk test were significantly associated with a walking AEX mode. In contrast, seated AEX did not have a significant effect on walking outcomes.

CONCLUSIONS

AEX significantly improves aerobic capacity poststroke, but may need to be task specific to affect walking speed and endurance. Higher AEX intensity is associated with better outcomes. Future randomized studies are needed to confirm these results.

Functional electrical stimulation cycling does not improve mobility in people with acquired brain injury and its effects on strength are unclear: a randomised trial

QUESTION

Does 4 weeks of active functional electrical stimulation (FES) cycling in addition to usual care improve mobility and strength more than usual care alone in people with a sub-acute acquired brain injury caused by stroke or trauma?

DESIGN

Multi centre, randomised, controlled trial.

PARTICIPANTS

Forty patients from three Sydney hospitals with recently acquired brain injury and a mean composite strength score in the affected lower limb of 7 (SD 5) out of 20 points.

INTERVENTION

Participants in the experimental group received an incremental, progressive, FES cycling program five times a week over a 4-week period. All participants received usual care.

OUTCOME MEASURES

Outcome measures were taken at baseline and at 4 weeks. Primary outcomes were mobility and strength of the knee extensors of the affected lower limb. Mobility was measured with three mobility items of the Functional Independence Measure and strength was measured with a hand-held dynamometer. Secondary outcomes were strength of the knee extensors of the unaffected lower limb, strength of key muscles of the affected lower limb and spasticity of the affected plantar flexors.

RESULTS

All but one participant completed the study. The mean between-group differences for mobility and strength of the knee extensors of the affected lower limb were -0.3/21 points (95% CI -3.2 to 2.7) and 7.5 Nm (95% CI -5.1 to 20.2), where positive values favoured the experimental group. The only secondary outcome that suggested a possible treatment effect was strength of key muscles of the affected lower limb with a mean between-group difference of 3.0/20 points (95% CI 1.3 to 4.8).

CONCLUSION

Functional electrical stimulation cycling does not improve mobility in people with acquired brain injury and its effects on strength are unclear.

TRIAL REGISTRATION

ACTRN12612001163897. [de Sousa DG, Harvey LA, Dorsch S, Leung J, Harris W (2016) Functional electrical stimulation cycling does not improve mobility in people with acquired brain injury and its effects on strength are unclear: a randomised controlled trial.Journal of Physiotherapy62: 203-208].

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.

Exercise stress testing after stroke or transient ischemic attack: a scoping review

OBJECTIVE

To provide insight into exercise stress testing after stroke or transient ischemic attack (TIA) in terms of feasibility, safety, and protocols used.

DATA SOURCES

PubMed, Embase, CINAHL, and Web of Science were searched for relevant studies published from inception to March 2014, and reference lists were hand searched.

STUDY SELECTION

To be included in the review, the articles needed to include participants diagnosed with stroke or TIA and have any form of test to assess exercise capacity.

DATA EXTRACTION

The scoping review methodology does not include critical appraisal of the literature but was chosen to reflect all aspects of exercise stress testing after stroke or TIA. Two reviewers performed screening for eligible studies independently, and 1 reviewer extracted the data.

DATA SYNTHESIS

We found a total of 112 studies involving 5008 participants describing symptom-limited (n=103), submaximal (n=9), and field (n=6) exercise stress test protocols. Some of the studies reported on data from >1 protocol. Metabolic analysis was included in 87% of the studies involving symptom-limited tests, 40% of submaximal studies, and 29% of field tests. Monitoring of blood pressure, perceived exertion, and electrocardiographic responses was done in 54%, 42%, and 95% of all studies, respectively. A mere 10% of all studies reported on electrocardiographic abnormalities detected during testing. No serious adverse events were reported.

CONCLUSIONS

Symptom-limited exercise stress testing appears to be safe in patients with stroke or TIA and provides a more valid measure of exercise capacity than submaximal and field tests. The level of disability may compromise feasibility, and test modality should be chosen carefully to optimize test results.

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.