Relative contributions of positive, negative, and adaptive features to limitations in upper-limb function three months after stroke

PURPOSE

To investigate the contributions of motor impairments to limitations in upper-limb function three months after stroke.

DESIGN

Cross-sectional, exploratory study.

METHODS

Dependent variable was upper-limb function, measured by the Motor Assessment Scale (MAS), which scores range from 0 to 18. Independent variables included measures of strength, dexterity, spasticity, and contracture of the paretic upper limb. Multiple linear regression analysis was employed to identify which of the independent variables could explain the MAS scores (p<0.05). Analysis was performed with the whole sample and with a sub-group of participants, who had high function (MAS≥12).

RESULTS

Sixty-nine individuals participated. Out of them, 63 had high upper-limb function. Regression analysis with the whole sample revealed that strength and dexterity were retained in the models. Together they explained 64% of the variance of the MAS scores (p<0.001), being strength the greater relative contributor. When the regression analysis included only participants with high upper-limb function, dexterity had a greater relative contribution, than strength. Together they explained 52 % of the variance (p< 0.001).

CONCLUSIONS

Strength was the main contributor to upper-limb function in individuals three months after stroke. However, in individuals, who already had higher upper-limb function, dexterity showed to be the major contributor.

Access to rehabilitation professionals by individuals with stroke one month after hospital discharge from a stroke unit in Brazil is insufficient regardless of the pandemic

OBJECTIVE

To compare access to rehabilitation professionals by individuals with stroke one month after hospital discharge from a stroke unit in Brazil, before and during the COVID-19 pandemic.

MATERIALS AND METHODS

This longitudinal and prospective study included individuals aged 20 years or older without previous disabilities admitted into a stroke unit due to a first stroke. Individuals were divided into two groups: before (G1) and during (G2) the COVID-19 pandemic. Groups were matched for age, sex, education level, socioeconomic status, and stroke severity. One month after hospital discharge, individuals were contacted via telephone to collect data regarding their access to rehabilitation services based on the number of referred rehabilitation professionals. Then, between-group comparisons were conducted (α = 5%).

RESULTS

The access to rehabilitation professionals was similar between groups. Rehabilitation professionals accessed included medical doctors, occupational therapists, physical therapists, and speech therapists. The first consultation after hospital discharge was mainly provided by public services. Despite the pandemic, telehealth was not frequent in any period evaluated. In both groups, the number of accessed professionals (G1 = 110 and G2 = 90) was significantly lower than the number of referrals (G1 = 212 and G2 = 194; p < 0.001).

CONCLUSIONS

Access to rehabilitation professionals was similar between groups. However, the number of accessed rehabilitation professionals was lower than that of referred ones during both periods. This finding indicates a compromised comprehensiveness of care for individuals with stroke, regardless of the pandemic.

Oxygen uptake efficiency slope in community-dwelling ambulant stroke survivors during walking and stair climbing: a cross-sectional study

BACKGROUND

Oxygen uptake efficiency slope during submaximal tests has been proposed as a more appropriate measure of aerobic capacity after suffering a stroke, since some individuals cannot tolerate maximal exercise testing. However, it has not yet been investigated whether the oxygen uptake efficiency slope is able to differentiate between healthy individuals and those who have suffered a stroke.

OBJECTIVES

To compare the oxygen uptake efficiency slope during walking and stair climbing between stroke survivors and age- and sex-matched healthy controls.

METHODS

This is a cross-sectional study in which 18 individuals who had suffered a stroke (stroke survivors) and 18 healthy controls matched for sex and age were included. Oxygen consumption and minute ventilation were collected breath-by-breath during walking (6-min Walk Test) and stair climbing. The oxygen uptake efficiency slope was estimated by the slope of the line obtained through linear regression.

RESULTS

The stroke survivors had a lower oxygen uptake efficiency slope during the 6-min Walk Test than the healthy controls (MD 498, 95% CI 122 to 873, p = .01). The between-group difference for the Stair Test was smaller and not statistically significant (MD 349, 95%CI -73 to 772, p = .10).

CONCLUSIONS

Stroke survivors had lower oxygen uptake efficiency slope during the performance of the 6-min Walk Test when compared to sex- and age-matched healthy controls. This suggests that stroke survivors have worse cardiopulmonary capacity.

Canes may not improve spatiotemporal parameters of walking after stroke: a systematic review of cross-sectional within-group experimental studies

PURPOSE

To examine whether using a cane would improve spatiotemporal parameters of walking, i.e., speed, stride length, cadence, and symmetry after stroke.

MATERIAL AND METHODS

Searches were conducted in eight databases. The experimental condition was walking with a cane. Four outcomes were of interest: walking speed, stride length, cadence, and symmetry.

RESULTS

Twelve studies were included. Results from nine studies suggested that individuals with stroke walked 0.01 m/s (SD 0.06) slower with a single-point cane, compared with no cane. Two studies suggested a reduction in cadence (MD-5 steps/min, SD2) and an increase in stride length (MD 0.08 m, SD 0.01). Three studies suggested that individuals walked 0.06 m/s (SD 0.07) slower with a four-point cane, compared with no cane. Four studies suggested that individuals walked 0.06 m/s (SD 0.04) faster with a single- point cane compared with a four-point cane. Results regarding other outcomes were inconclusive.

CONCLUSIONS

Results showed no worthwhile improvements in spatiotemporal parameters of walking with a single-point cane and a slight reduction with a four-point cane, compared with no cane. Individuals walked slightly faster with a single-point cane compared with a four-point cane, but the evidence is insufficient to support this superiority.IMPLICATIONS FOR REHABILITATIONA single-point cane may not improve spatiotemporal parameters of walking after stroke.Walking with a four-point cane may slightly decrease spatiotemporal parameters of walking.Canes may be prescribed without the fear of negatively impairing walking kinematics.

Cross-cultural adaptation and measurement properties of the Brazilian Portuguese version of the spinal cord injury - Falls Concern Scale

STUDY DESIGN

Psychometric study.

OBJECTIVES

To cross-culturally adapt the spinal cord injury-falls concern scale (SCI-FCS) to the Brazilian Portuguese language and to evaluate its measurement properties.

SETTING

SARAH Network of Rehabilitation Hospitals, Belo Horizonte, Brazil.

METHODS

The SCI-FCS was translated and culturally adapted to the Brazilian- Portuguese language, following recommended guidelines. The following measurement properties were verified: internal consistency (Cronbach's α), test-retest reliability (ICC and quadratic-weighted kappa coefficients), and construct validity (Rasch analysis).

RESULTS

One-hundred and thirty individuals participated. The median SCI-FCS-Brazil score was 27 (22-34). The Cronbach's α was 0.95; ICC was 0.92 (95% CI, 0.86-0.95) for the total test-retest scores, and the Kappa coefficients ranged from 0.04 to 0.87 (95% CI, 0.01-1) for the item-level reliability. Rasch analysis reliability index was 0.81 and 0.98 and the separation index was 2.10 and 6.25 for the persons and items, respectively. Both items and persons fitted the statistics model's expectations, ensuring its unidimensionality.

CONCLUSIONS

The SCI-FCS-Brazil showed adequate measurement properties. Its use in manual wheelchair users with SCI is recommended to help defining rehabilitation strategies.

Test-retest reliability and measurement error of the modified gait efficacy scale in individuals with stroke

PURPOSE

To investigate the test-retest reliability and measurement error of the Brazilian version of the modified Gait Efficacy scale (mGES-Brazil) in individuals who have had stroke.

METHODS

The mGES-Brazil was applied on two occasions, five to seven days apart, in a research laboratory setting. Test-retest reliability and measurement error, which included the standard error of measurement (SEM), smallest detectable change (SDC), and analysis of the limits of agreement by the Bland-Altman plots, were examined.

RESULTS

Fifty individuals who have had stroke (18 men), with a mean age of 64 ± 11 years, were evaluated. All individual items showed good reliability (Intra-class Correlation Coefficient - ICC_2,1 > 0.90). The ICC was 0.98 (95% CI 0.97 to 0.99) and the Bland and Altman plots revealed no systematic changes in the mean test-retest scores. The SEM (SEM%) was 3 (5%), within the recommended values, while the SDC was 8 points.

CONCLUSION

The mGES-Brazil demonstrated to be reliable to be applied within clinical and research contexts for the assessment of changes in walking confidence of individuals who have had stroke. Changes in mGES scores ≥8 points reflect real changes.

Validation of the telephone-based assessment of locomotion ability after stroke

The aim of the study was to validate the telephone-based application of the ABILOCO questionnaire for the assessment of locomotion ability after stroke. Individuals after stroke answered the ABILOCO-Brazil questionnaire on two randomized occasions, face-to-face and by telephone, 5-7 days apart. The mean difference between the interviews was reported. Intraclass correlation coefficient (ICC) was calculated to investigate the agreement between the total scores, and weighted-Kappa statistics to investigate the agreement between the individual items. A total of 92 individuals were included. There was no significant difference in the mean scores between face-to-face and telephone-based applications of the ABILOCO [mean difference 0.17 logits; 95% confidence interval (CI), -0.88 to 0.54]. A high level of agreement was found between the ABILOCO total scores obtained between both applications (ICC = 0.90; 95% CI, 0.84-0.93), and most of the individual items had, on average, moderate agreement. The ABILOCO showed to be a reliable questionnaire for telephone assessment of locomotion ability after stroke.

Self-Efficacy to Engage in Physical Exercise and Walking Ability Best Predicted Exercise Adherence after Stroke

AIM

To describe exercise preferences and to investigate the contribution of exercise preferences, walking ability, and current levels of physical activity in predicting exercise adherence in individuals with chronic stroke.

METHODS

For this exploratory study, exercise adherence was measured using the first question of the first section of the Exercise Preference Questionnaire (stroke)-Brazil (EPQ (stroke)-Brazil). Nine independent variables were included as potential predictors of exercise adherence: the seven factors of the EPQ (stroke)-Brazil, walking speed, and level of physical activity.

RESULTS

Participated 93 individuals with stroke, who had a mean age of 62 (SD 12) years and a mean time since the onset of the stroke of 58 (SD 67) months. The most preferable exercise was walking. Logistic regression analysis revealed that self-efficacy to engage in physical exercise and walking ability predicted and explained 80% of the variance in exercise adherence.

CONCLUSION

The findings showed that feeling able to perform physical exercise and having higher walking ability predicted higher exercise adherences in individuals with chronic stroke. The knowledge of potential contributors to exercise adherence may help in designing exercise programs for individuals with stroke.

Community-dwelling individuals with stroke, who have inspiratory muscle weakness, report greater dyspnea and worse quality of life

The objective of the present study was to investigate if different levels of inspiratory muscle strength would be associated with dyspnea, walking capacity, and quality of life after stroke. For this exploratory study, the dependent outcome was strength of the inspiratory muscles, measured by maximal inspiratory pressure. Individuals with maximal inspiratory pressure ≥80 cmH2O were classified as non-weak, those with maximal inspiratory pressure between 45 and 80 cmH2O were classified as weak, and those with maximal inspiratory pressure ≤45 cmH2O were classified as very weak. Related outcomes included dyspnea, measured by the modified Medical Research Council scale; walking capacity, measured by the 6-minute walk test; and quality of life, measured by the Stroke-Specific Quality of Life scale. Fifty-three participants, who had a mean age of 62 years (SD 12) and a mean time since the onset of the stroke of 20 (SD 17) months were included. Significant differences were found only between the weak/very weak and non-weak groups. The mean differences between the non-weak and weak/very weak participants were -1.8 points (95% confidence interval -2.7 to -0.9) for dyspnea and 55 points (95% confidence interval 22-88) for quality of life. Significant correlations were found between measures of inspiratory strength and dyspnea (r = -0.54; P < 0.01) and quality of life (r = 0.56; P < 0.01). There were not found any significant differences or correlations regarding walking capacity. The findings demonstrated that individuals with stroke, who had weakness of the inspiratory muscles, reported greater dyspnea and worse quality of life, compared with those, who did not have weakness. The results regarding walking capacity remain unclear.

Associations between walking speed and participation, according to walking status in individuals with chronic stroke

BACKGROUND

Reduced walking speed (WS) may lead to restrictions in participation of individuals with stroke, however, the relationships between WS and participation still need to better clarified.

OBJECTIVE

To evaluate the relationships between WS and participation and compare the levels of participation of individuals with chronic stroke, who were stratified according to their walking status.

METHODS

One-hundred and five individuals with stroke (58±12 years; 61 men) participated. WS was measured by the 10-meter walking test and reported in m/s. The participants were stratified into three walking status groups: household (WS <0.4 m/s), limited-community (0.4 m/s-0.8 m/s), and full-community ambulation (>0.8 m/s). Participation was assessed by the Brazilian version of the Assessment of Life Habits 3.1 (LIFE-H 3.1-Brazil).

RESULTS

Between-group analyses revealed statistically significant differences between the household, limited-community, and full-community ambulators regarding the LIFE-H 3.1 total (F = 17.5; p < 0.0001), as well the daily activity (F = 12.3; p < 0.0001) and social role (F = 19.0; p < 0.0001) domain scores. Measures of WS were correlated with the daily activity (r = 0.50, p < 0.0001), social role (r = 0.53, p < 0.0001), total LIFE-H scores (r = 0.53, p < 0.0001), and most of the LIFE-H categories (r = 0.23-0.56).

CONCLUSIONS

WS was significantly correlated with participation and was able to distinguish between individuals with stroke, who had different levels of participation.

Incidence and potential predictors of early onset of upper-limb contractures after stroke

OBJECTIVES

To investigate the incidence and potential predictors of upper-limb contractures, three months after stroke.

DESIGN

Prospective cohort study.

METHODS

Consecutive sample of individuals with hemiparesis due to stroke, admitted to a public hospital in Brazil. Contractures were measured by passive range of motion of lateral shoulder rotation, elbow extension, and wrist extension with a gravity inclinometer. Potential predictors included measures of muscle strength, spasticity of the upper-limb muscles, upper-limb function, dexterity, and pain. Measurements were obtained within four weeks and at three months after the stroke. A binomial regression analysis was employed.

RESULTS

Out of the 76 individuals with hemiparesis, 28% developed at least one contracture on their paretic upper limb. The incidence of contracture varied across the joints from 6% to 16% and the wrist was the most affected joint. Individuals with moderate stroke showed higher incidence of contracture, compared with those with mild stroke. Dexterity (OR 0.009, 95% confidence intervals (95% CI) 0.00-0.19) and pain (OR 6.417, 95% CI 1.22-33.83) were significant predictors of shoulder, elbow, and wrist contractures.

CONCLUSIONS

Individuals with mild and moderate stroke developed upper-limb contractures three months after the onset of the stroke, with an incidence of 28%. The predictors were the presence of pain and loss of dexterity. These impairments should be earlier targeted during rehabilitation interventions.Implications for rehabilitationThe incidence of upper limb contracture 3 months after the stroke is high after mild to moderate stroke.Wrist contractures are the most common upper limb contracture.The presence of pain and loss of dexterity significantly contribute to the development of upper limb contractures.Health professionals should target on the control of pain and improvement of upper-limb dexterity to prevent contractures.

Predictors of return to work after stroke: a prospective, observational cohort study with 6 months follow-up

PURPOSE

To determine, in Brazil, the proportion of individuals who return to a paid work after stroke, and the factors which predict this.

MATERIALS AND METHODS

A prospective observational cohort study was carried out for six months. Participants were recruited early after stroke from four public hospitals. The outcome of interest was return to work, and the following predictors were investigated: age, sex, education, marital status, contribution to household income, type of work, independence, and depression. Logistic regression was used to identify multivariate predictors of return to work.

RESULTS

Of the 117 included participants, 52 (44%) had returned to work by 6 months. Contribution to household income (OR 2.4; 95% CI 1.0 to 5.9), being a white-collar worker (OR 4.0; 95% CI 1.8 to 8.6) and being independent in daily activities at 3 months (OR 10.6; 95% CI 2.9 to 38.3), in combination, positively predicted return to work.

CONCLUSIONS

Less than 50% of stroke survivors returned to work six months after stroke. Among predictors, only the level of dependence in daily activities is a modifiable factor. Interventions aimed at reducing disability after stroke might increase rates of return to work.Implications for rehabilitationIn Brazil, less than 50% of stroke survivors returned to work six months after stroke.Clinicians may collect information regarding household income, type of work and dependence in daily activities to estimate chances of returning to work, in developing countries.Being independent at 3 months was the strongest predictor of return to work; therefore, interventions aimed at reducing disability after stroke may increase rates of return to work.

Walking speed best explains perceived locomotion ability in ambulatory people with chronic stroke, assessed by the ABILOCO questionnaire

BACKGROUND

The identification of the predictors of locomotion ability could help professionals select variables to be considered during clinical evaluations and interventions.

OBJECTIVE

To investigate which impairment measures would best predict locomotion ability in people with chronic stroke.

METHODS

Individuals (n=115) with a chronic stroke were assessed. Predictors were characteristics of the participants (i.e. age, sex, and time since stroke), motor impairments (i.e. muscle tonus, strength, and motor coordination), and activity limitation (i.e. walking speed). The outcome of interest was the ABILOCO scores, a self-reported questionnaire for the assessment of locomotion ability, designed specifically for individuals who have suffered a stroke.

RESULTS

Age, sex, and time since stroke did not significantly correlate with the ABILOCO scores (-0.07<ρ<0.05; 0.48<p<0.99). Measures of motor impairments and walking speed were significantly correlated with the ABILOCO scores (-0.25<r<0.57; p<0.001), but only walking speed and strength were kept in the regression model. Walking speed alone explained 35% (F=55.5; p<0.001) of the variance in self-reported locomotion ability. When strength was included in the model, the explained variance increased to 37% (F=31.4; p<0.001).

CONCLUSIONS

Walking speed and lower limb strength best predicted locomotion ability as perceived by individuals who have suffered a stroke.

Prevalence of dyspnea after stroke: a telephone-based survey

OBJECTIVE

Dyspnea is a relevant outcome to be taken into consideration during stroke rehabilitation. Prevalence, severity, and effects of this condition on individuals with stroke remain uncertain. This study investigated the prevalence and severity of dyspnea after a stroke, as well the associations between dyspnea, activity limitations, and participation restrictions.

METHODS

A telephone-based survey was conducted with 285 individuals with stroke. The survey included information regarding the onset and severity of the dyspnea, activity limitations, and participation restrictions. Prevalence of dyspnea was reported as percentage of individuals who had the symptom. Chi-square tests were used to investigate the associations between dyspnea, activity limitations, and participation restrictions. Relative risks and respective 95% confidence intervals were calculated.

RESULTS

Out of the 285 participants, 124 (44%) reported having dyspnea after stroke. Severe symptoms were reported by 51% of the participants with dyspnea. In addition, dyspnea limited activity and restricted social participation in 85% and 49% of the participants, respectively. Dyspnea was significantly correlated with activity limitations (r=0.87; 95% CI 0.82-0.92; p<0.01) and participation restrictions (r=0.53; 95% CI 0.46-0.62; p<0.01). The analyses indicated that individuals with dyspnea were more likely to report that it limited their activities (RR: 6.5; 95% CI 4.3-9.9) and restricted social participation (RR: 1.7; 95% CI 1.5-2.0).

CONCLUSIONS

Dyspnea is an important symptom after stroke and showed to be associated with activity limitations and restrictions in community participation. Earlier detection of dyspnea in people with stroke, followed by appropriate management, is strongly recommended and has the potential to improve activity and social participation.

Validity of the accelerometer and smartphone application in estimating energy expenditure in individuals with chronic stroke

OBJECTIVE

To examine the concurrent validity of the GT3X^® ActiGraph accelerometer and Google Fit^® smartphone application in estimating energy expenditure in people who had suffered a stroke, during fast overground walking.

METHODS

Thirty community-dwelling stroke individuals walked on a 10-meter hallway over 5min at their fastest speeds, wearing a Cortex Metamax 3B^® ergoespirometer, a GT3X^® ActiGraph accelerometer, and a smartphone with the Google Fit^® application. Pearson correlation coefficients were calculated to verify the associations between measures of energy expenditure, in kilocalories (kcal), estimated by both devices and those obtained with the Cortex Metamax 3B^® ergoespirometer (gold-standard measure).

RESULTS

Fair association was found between the energy expenditure values estimated from the combined formula of the ActiGraph GT3X^® and those obtained with the gold-standard measure (r=0.37; p=0.04). No significant associations were found between the energy expenditure values estimated by the Google Fit^® application and those provided by the gold-standard measure.

CONCLUSIONS

The findings demonstrated that both the GT3X^®ActiGraph accelerometer and the Google Fit^® smartphone application do not provide valid measures of energy expenditure in chronic stroke individuals during fast overground walking.

Efficacy of Interventions to Improve Respiratory Function After Stroke

BACKGROUND

The aim of this study was to systematically review all current interventions that have been utilized to improve respiratory function and activity after stroke.

METHODS

Specific searches were conducted. The experimental intervention had to be planned, structured, repetitive, purposive, and delivered with the aim of improving respiratory function. Outcomes included respiratory strength (maximum inspiratory pressure [P_Imax], maximum expiratory pressure [P_Emax]) and endurance, lung function (FVC, FEV₁, and peak expiratory flow [PEF]), dyspnea, and activity. The quality of the randomized trials was assessed by the PEDro scale using scores from the Physiotherapy Evidence Database (www.pedro.org.au), and risk of bias was assessed in accordance with the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

The 17 included trials had a mean PEDro score of 5.7 (range 4-8) and involved 616 participants. Meta-analyses showed that respiratory muscle training significantly improved all outcomes of interest: P_Imax (weighted mean difference 11 cm H₂O, 95% CI 7-15, I² = 0%), P_Emax (8 cm H₂O, 95% CI 2-15, I² = 65%), FVC (0.25 L, 95% CI 0.12-0.37, I² = 29%), FEV₁ (0.24 L, 95% CI 0.17-0.30, I² = 0%), PEF (0.51 L/s, 95% CI 0.10-0.92, I² = 0%), dyspnea (standardized mean difference -1.6 points, 95% CI -2.2 to -0.9; I² = 0%), and activity (standardized mean difference 0.78, 95% CI 0.22-1.35, I² = 0%). Meta-analyses found no significant results for the effects of breathing exercises on lung function. For the remaining interventions (ie, aerobic and postural exercises) and the addition of electrical stimulation, meta-analyses could not be performed.

CONCLUSIONS

This systematic review reports 5 possible interventions used to improve respiratory function after stroke. Respiratory muscle training proved to be effective for improving inspiratory and expiratory strength, lung function, and dyspnea, and benefits were carried over to activity. However, there is still no evidence to accept or refute the efficacy of aerobic, breathing, and postural exercises, or the addition of electrical stimulation in respiratory function.

Twin studies for the prognosis, prevention and treatment of musculoskeletal conditions

BACKGROUND

Musculoskeletal conditions are highly prevalent in our ageing society and are therefore incurring substantial increases in population levels of years lived with disability (YLD). An evidence-based approach to the prognosis, prevention, and treatment of those disorders can allow an overall improvement in the quality of life of patients, while also softening the burden on national health care systems.

METHODS

In this Masterclass article, we provide an overview of the most relevant twin study designs, their advantages, limitations and major contributions to the investigation of traits related to the domain of musculoskeletal physical therapy.

CONCLUSIONS

Twin studies can be an important scientific tool to address issues related to musculoskeletal conditions. They allow researchers to understand how genes and environment combine to influence human health and disease. Twin registries and international collaboration through existing networks can provide resources for achieving large sample sizes and access to expertise in study design and analysis of twin data.

Cross-cultural adaptation and measurement properties of the Brazilian version of the Exercise Preference Questionnaire(stroke)

BACKGROUND

The Exercise Preference Questionnaire (EPQ(stroke)) captures exercise preferences and measures personal factors, that influence motivation and adherence to exercise in stroke subjects.

OBJECTIVES

To perform the cross-cultural adaptation of the EPQ(stroke) into the Brazilian-Portuguese language and to evaluate its measurement properties.

METHODS

The EPQ(stroke) was cross-culturally adapted and primarily tested in 30 chronic stroke subjects. After the final version of the EPQ(stroke)-Brazil was created, its test-retest reliability was verified, using Kappa indices and intra-class correlation coefficients (ICCs) (n=50), and internal consistency was verified using Cronbach's alpha coefficients (n=101). Construct validity was assessed using exploratory factor analysis (n=101), content validity using the content validity index (CVI) (n=8), and face validity using the rate of agreement regarding the clarity, wording, ability to answer the questions, and lay-out and style of the questionnaire with two groups, including individuals with stroke (n=81) and multidisciplinary health professionals (n=32).

RESULTS

The pre-final version required revisions (items 9, 29, and 30) and, after another pre-test, it was shown to be appropriate. The Kappa indices ranged from 0.58 to 0.95; the ICCs from 0.35 to 0.93, and the Cronbach's alpha coefficient was 0.82 (0.768-0.869 CI), showing adequate internal consistency. The exploratory factor analysis and CVI confirmed the validity of the EPQ(stroke)-Brazil. The rate of agreement was greater than 80% for both groups.

CONCLUSION

The EPQ(stroke)-Brazil was found to be a valid and reliable measure for verifying exercise preferences of Brazilian individuals with stroke.

Relationship between oxygen cost of walking and level of walking disability after stroke: An experimental study

BACKGROUND AND PURPOSE

Since physical inactivity is the major risk factor for recurrent stroke, it is important to understand how level of disability impacts oxygen uptake by people after stroke. This study investigated the nature of the relationship between level of disability and oxygen cost in people with chronic stroke.

METHODS

Level of walking disability was measured as comfortable walking speed using the 10-m Walk Test reported in m/s with 55 ambulatory people 2 years after stroke. Oxygen cost was measured during 3 walking tasks: overground walking at comfortable speed, overground walking at fast speed, and stair walking at comfortable speed. Oxygen cost was calculated from oxygen uptake divided by distance covered during walking and reported in ml∙kg^-1 ∙m^-1 .

RESULTS

The relationship between level of walking disability and oxygen cost was curvilinear for all 3 walking tasks. One quadratic model accounted for 81% (95% CI [74, 88]) of the variance in oxygen cost during the 3 walking tasks: [Formula: see text] DISCUSSION: The oxygen cost of walking was related the level of walking disability in people with chronic stroke, such that the more disabled the individual, the higher the oxygen cost of walking; with oxygen cost rising sharply as disability became severe. An equation that relates oxygen cost during different walking tasks according to the level of walking disability allows clinicians to determine oxygen cost indirectly without the difficulty of measuring oxygen uptake directly.

Energy expenditure and cost of walking and stair climbing in individuals with chronic stroke

•

Stroke subjects had lower EE during the 6MWT and SCT compared to the healthy subjects.

•

Stroke subjects had higher EC during the 6MWT and SCT compared to the healthy subjects.

•

Walking speed differentiated healthy from stroke subjects gait.

•

The stroke subjects who walked faster showed better energy efficiency.

•

Evidence-based interventions to improve walking speed should be implemented.

Background

Subjects with stroke show higher energy cost (EC) during walking, when compared to healthy individuals, but the mechanisms are not fully understood. Additionally, the behavior of physiological variables during other activities has not been investigated.

Objectives

To investigate energy expenditure (EE) and EC during the six-minute walking test (6MWT) and stair climb test (SCT) in chronic stroke subjects compared to healthy controls.

Methods

Cross-sectional study in which stroke subjects (n = 18) (community-walking speed ≥0.8 m/s) or limited-community <0.8 m/s walkers and matched healthy controls (n = 18) had their EE and EC assessed during the 6MWT and SCT with a portable monitoring system.

Results

Significant differences in EE were observed for both the 6MWT (MD 7.29; 95%CI 4.08–10.50) and SCT (MD 8.53; 95%CI 5.07–12.00) between the stroke and control groups, but not between the stroke subgroups. Significant between-group differences in EC were found for both the 6MWT and SCT. For the 6MWT, differences were significant between the limited-community and the community walkers (MD 0.19; 95%CI 0.05–0.33) and controls (MD 0.17; 95%CI 0.04–0.29). No significant differences were found between the community walkers and controls (MD 0.02; 95%CI −0.09 to 0.13). For the SCT, the limited-community walkers showed highest EC, followed by the community walkers, and controls.

Conclusions

Both stroke subgroups demonstrated lower EE compared to healthy controls. During the 6MWT, the limited-community walkers demonstrated higher EC compared to the community walkers and controls. During the SCT, the limited-community walkers demonstrated higher EC, followed by the community walkers, and controls.

Performance and capacity-based measures of locomotion, compared to impairment-based measures, best predicted participation in individuals with hemiparesis due to stroke

PURPOSE

To determine the potential predictors of participation of individuals with post-stroke hemiparesis, taking into account modifiable variables of impairments, activity limitations, and environmental factors.

METHODS

One hundred and nine individuals (58 ± 12 years; 64 men) participated in this study. Outcomes included measures of impairments (depressive symptoms: Geriatric Depression Scale and motor-based impairments: finger-to-nose test, lower extremity (LE) motor coordination test, and handgrip strength, isometric strength of the LE muscles), activity (capacity: 10-meter walking speed test and Test d'Évaluation des Membres Supérieurs de Personnes Agées; performance: locomotion and manual abilities; environmental factors (Measure of the Quality of the Environment); and participation: Assessment of Life Habits (LIFE-H 3.1 Brazil)).

RESULTS

Regression analyses revealed that the explanatory variables accounted for 59% and 49% of the variance in the LIFE-H 3.1 Brazil daily activity and social role sub-scales, respectively. Locomotion performance (R² = 39%; p < 0.0001) and walking speed (R² = 32%; p < 0.0001) were the best predictors of the LIFE-H 3.1 Brazil daily activity and social role sub-scales, respectively. Depressive symptoms were the only impairments, which were retained in both models.

CONCLUSIONS

Performance and capacity-based measures of locomotion showed to be the best predictors of participation. Additionally, depressive symptoms should not be underlooked. Implications for Rehabilitation Activity-related measures of locomotion showed to be the main predictors of participation in individuals with post-stroke hemiparesis, as assessed by the daily activity and social role sub-scales of the LIFE-H 3.1. The daily activity model was best predicted by measures of performance, whereas the social role sub-scale, by measures of capacity. Although small, the impact of depressive symptoms on participation should not be underlooked. Locomotion appeared to be essential for participation and increases in walking speed and locomotion ability should be the main goals for both professionals and individuals, when the aim is to increase participation.

Lower-limb motor coordination is significantly impaired in ambulatory people with chronic stroke: A cross-sectional study

OBJECTIVES

To establish the deficits of motor coordination of the lower limbs after stroke, in comparison with healthy controls, and to investigate whether the magnitude of the deficits would be influenced by the levels of motor recovery.

DESIGN

Cross-sectional study.

SUBJECTS

Chronic stroke patients and healthy subjects.

METHODS

Lower-limb motor coordination of both stroke and healthy volunteers was measured using the Lower Extremity Motor Coordination Test (LEMOCOT). The motor coordination deficits of the participants with stroke were analysed all together and separated, according to their levels of motor recovery, measured using the Fugl-Meyer lower-limb motor section scores.

RESULTS

Ninety-seven individuals with chronic stroke, 55 men, mean age 58 years, were evaluated. Motor coordination was significantly impaired on both paretic (mean: -22 touches; 95% confidence interval (95% CI) -24 to -19; deficit: 61%) and non-paretic (mean -6 touches; 95% CI -8 to -4; deficit: 17%) lower limbs. Significant differences in the LEMOCOT scores were found between the levels of motor recovery (p < 0.01), except between the participants with marked and moderate impairments.

CONCLUSION

Motor coordination of the lower limbs is significantly impaired after stroke, but the deficits of the non-paretic lower limb (17%) appear not to be clinically relevant. These findings suggest that interventions prescribed to improve motor coordination after stroke should focus on the paretic lower limb and/or include bilateral activities.

Efficacy of interventions to improve physical activity levels in individuals with stroke: a systematic review protocol

INTRODUCTION

Stroke is a leading health problem worldwide and an important cause of disability. Stroke survivors show low levels of physical activity, and increases in physical activity levels may improve function and health status. Therefore, the aims are to identify which interventions that have been employed to increase physical activity levels with stroke survivors, to verify their efficacy and to identify the gaps in the literature.

METHODS AND ANALYSIS

A systematic review of randomised controlled trials that investigated the efficacy of interventions aiming at increasing physical activity levels of stroke survivors will be conducted. Electronic searches will be performed in the MEDLINE, Physiotherapy Evidence Database (PEDro), Excerpta Medica (EMBASE), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) and Scientific Electronic Library Online (SCIELO) databases. Hand searches of the reference lists of the included studies or relevant reviews will also be employed. Two independent reviewers will screen all the retrieved titles, abstracts and full texts. A third reviewer will be referred to solve any disagreements. The quality of the included studies will be assessed by the PEDro Rating Scale. This systematic review will also include a qualitative synthesis. Meta-analyses will be performed, if the studies are sufficiently homogeneous. This review will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The quality of the evidence regarding physical activity will be assessed, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

DISCUSSION

This systematic review will provide information on which interventions are effective for increasing physical activity levels of stroke survivors. This evidence may be important for clinical decision-making and will allow the identification of gaps in the literature that may be useful for the definition of future research goals and the planning of new trials.

TRIAL REGISTRATION NUMBER

CRD42016037750.

Walking training associated with virtual reality-based training increases walking speed of individuals with chronic stroke: systematic review with meta-analysis

OBJECTIVE:

To systematically review the available evidence on the efficacy of walking training associated with virtual reality-based training in patients with stroke. The specific questions were: Is walking training associated with virtual reality-based training effective in increasing walking speed after stroke? Is this type of intervention more effective in increasing walking speed, than non-virtual reality-based walking interventions?

METHOD:

A systematic review with meta-analysis of randomized clinical trials was conducted. Participants were adults with chronic stroke and the experimental intervention was walking training associated with virtual reality-based training to increase walking speed. The outcome data regarding walking speed were extracted from the eligible trials and were combined using a meta-analysis approach.

RESULTS:

Seven trials representing eight comparisons were included in this systematic review. Overall, the virtual reality-based training increased walking speed by 0.17 m/s (IC 95% 0.08 to 0.26), compared with placebo/nothing or non-walking interventions. In addition, the virtual reality-based training increased walking speed by 0.15 m/s (IC 95% 0.05 to 0.24), compared with non-virtual reality walking interventions.

CONCLUSIONS:

This review provided evidence that walking training associated with virtual reality-based training was effective in increasing walking speed after stroke, and resulted in better results than non-virtual reality interventions.

Previous lower limb dominance does not affect measures of impairment and activity after stroke

BACKGROUND

Similar to the findings with the upper limbs, previous dominance of the lower limbs could also interfere with measures of impairment and activity of individuals with stroke. If this occurs, rehabilitation interventions should be planned, considering previous lower limb dominance.

AIM

To investigate the impact of having the dominant versus the non-dominant lower limb affected by the stroke on measures of impairment and activity.

DESIGN

Cross-sectional study.

SETTING

University laboratory.

POPULATION

Ninety subjects with chronic stroke, divided into dominant (n=44) and non-dominant (N.=46) groups.

METHODS

The sub-groups were classified according to the severity of motor impairments into mild and severe. Impairment measures included sensation, tonus, isometric strength and motor coordination, whereas activity measures included walking speed, and stair ascent/descent cadences.

RESULTS

The MANOVAs did not reveal any significant interactions between dominance and severity of motor impairments for both the impairment and activity models. Significant main effects of severity of motor impairments were found for both the impairment and activity models, but not for dominance. All dependent variables were significantly affected by the severity of motor impairments, but not by dominance.

CONCLUSIONS

The findings suggested that individuals, who had their dominant lower limb affected by the stroke, demonstrated similar impairments, than those who had the non-dominant lower limb affected. Furthermore, significant effects of severity of motor impairments, but not of dominance, were found on all measures of impairment and activity.

CLINICAL REHABILITATION IMPACT

The findings emphasize the importance of not training the lower limbs based upon previous dominance, but giving priority to bilateral training. When both limbs are simultaneously used in tasks, the movement of the non-dominant limb improves the quality of the movement, accuracy, and speed, because bilateral training helps the unaffected side to train the affected side.

Modified sphygmomanometer test for the assessment of strength of the trunk, upper and lower limbs muscles in subjects with subacute stroke: reliability and validity

BACKGROUND

Limitations in activities have been related to weakness of the upper limbs (UL), lower limbs (LL) and trunk muscles after stroke. Therefore, the measurement of strength after stroke becomes essential. The Modified Sphygmomanometer Test (MST) is an alternative method for the measurement of strength, since it is cheap and provides objective values. However, no studies have investigated the measurement properties of the MST in sub-acute stroke.

AIM

To investigate the test-retest and inter-rater reliabilities and criterion-related validity of the MST for the measurement of strength of the UL, LL, and trunk muscles in subjects with sub-acute stroke, and verify whether the number of trials would affect the results.

DESIGN

Diagnostic accuracy.

SETTING

Local community, out-patient clinics, and university laboratory.

POPULATION

Sixty- five subjects with sub-acute stroke (62±14 years) participated of the present study.

METHODS

The strength of 36 muscular groups was measured with the MST and dynamometers (criterion standard). To investigate whether the number of trials would affect the results, analysis of variance was applied. For the test-retest and inter-rater reliabilities and criterion-related validity of the MST, intra-class correlation coefficients (ICC), Pearson correlation coefficients, and coefficients of determination were calculated.

RESULTS

Similar results were found for all muscular groups and number of trials (0.01≤F≤0.14; 0.87≤p≤0.99) with significant and adequate values of test-retest (0.57≤ICC≥0.98) (exception: first trial of the non-paretic ankle dorsiflexors) and inter-rater (0.50≤ICC≥0.99) (exception: non-paretic ankle plantar flexors) reliabilities and validity (0.70≤r≥0.95; p≤0.001). The values obtained with the MST were good predictors of those obtained with the dynamometers (0.54≤r2≤0.90).

CONCLUSIONS

In general, the MST showed adequate reliabilities and criterion-related validity for measuring strength of subjects with sub-acute stroke, and only one trial, after familiarization, provided adequate values.

CLINICAL REHABILITATION IMPACT

The MST can be used by health professionals within several clinical contexts to objectively measure strength of the UL, LL, and trunk muscles in subjects with sub-acute stroke. Besides providing objective, reliable, and valid strength measures, the MST is also feasible. The aneroid sphygmomanometer used for the MST assessment is portable, easily found worldwide, and commonly acquired by health professionals. Furthermore, its adaptation is simple, reversible, and cheap.

Dynamometry for the measurement of grip, pinch, and trunk muscles strength in subjects with subacute stroke: reliability and different number of trials

Background

Muscle strength is usually measured in individuals with stroke with Portable dynamometers (gold standard). However, no studies have investigated the reliability, the standard error of measurement (SEM) and the minimal detectable difference (MDD_95%) of the dynamometry for the measurement of hand grip, pinch grip and trunk strength in subjects with subacute stroke.

Objective

1) To investigate the intra and inter-rater reliability, the SEM and the MDD_95% of the portable dynamometers for the measurement of grip, pinch and trunk strength in subjects with subacute stroke, and 2) to verify whether the use of different number of trials (first trial and the average of the first two and three trials) affected the results.

Method

32 subjects with subacute stroke (time since stroke onset: 3.6 months, SD=0.66 months) were evaluated. Hand grip, 3 pinch grips (i.e. pulp-to-pulp/palmar/lateral) and 4 trunk muscles (i.e. flexors, extensors, lateral flexors and rotators) strength were bilaterally assessed (except trunk flexors/extensors) with portable dynamometry by two independent examiners over two sessions (1-2 weeks apart). One-way ANOVAs and intraclass correlation coefficients (ICC_2,k) were used for analysis (α=0.05). SEM and MDD_95% were also calculated.

Results

For all muscular groups and sources of outcome values, including one trial, after familiarization, similar results were found (0.01≤F≤0.08; 0.92≤p≤0.99) with significant and adequate values of intra-rater (0.64≤ICC≤0.99; 0.23≤95%CI≤0.99) and inter-rater (0.66≤ICC≤0.99; 0.25≤95%CI≤0.99) reliability. SEM and MDD_95% were considered low (0.39≤EPM≤2.21 Kg; 0.96≤MMD_95%≤6.12 Kg) for all outcome scores.

Conclusion

Only one trial, following familiarization, demonstrated adequate intra-rater and inter-rater reliability of the portable dynamometers for the measurement of hand grip, pinch grip and trunk strength in subjects with subacute stroke.

Respiratory muscle training increases respiratory muscle strength and reduces respiratory complications after stroke: a systematic review

QUESTION

After stroke, does respiratory muscle training increase respiratory muscle strength and/or endurance? Are any benefits carried over to activity and/or participation? Does it reduce respiratory complications?

DESIGN

Systematic review of randomised or quasi-randomised trials.

PARTICIPANTS

Adults with respiratory muscle weakness following stroke.

INTERVENTION

Respiratory muscle training aimed at increasing inspiratory and/or expiratory muscle strength.

OUTCOME MEASURES

Five outcomes were of interest: respiratory muscle strength, respiratory muscle endurance, activity, participation and respiratory complications.

RESULTS

Five trials involving 263 participants were included. The mean PEDro score was 6.4 (range 3 to 8), showing moderate methodological quality. Random-effects meta-analyses showed that respiratory muscle training increased maximal inspiratory pressure by 7 cmH2O (95% CI 1 to 14) and maximal expiratory pressure by 13 cmH2O (95% CI 1 to 25); it also decreased the risk of respiratory complications (RR 0.38, 95% CI 0.15 to 0.96) compared with no/sham respiratory intervention. Whether these effects carry over to activity and participation remains uncertain.

CONCLUSION

This systematic review provided evidence that respiratory muscle training is effective after stroke. Meta-analyses based on five trials indicated that 30minutes of respiratory muscle training, five times per week, for 5 weeks can be expected to increase respiratory muscle strength in very weak individuals after stroke. In addition, respiratory muscle training is expected to reduce the risk of respiratory complications after stroke. Further studies are warranted to investigate whether the benefits are carried over to activity and participation.

REGISTRATION

PROSPERO (CRD42015020683). [Menezes KKP, Nascimento LR, Ada L, Polese JC, Avelino PR, Teixeira-Salmela LF (2016) Respiratory muscle training increases respiratory muscle strength and reduces respiratory complications after stroke: a systematic review.Journal of Physiotherapy62: 138-144].

Potential predictors of lower extremity impairments in motor coordination of stroke survivors

BACKGROUND

It is well recognized that the negative motor impairments following upper motor neuron damage, e.g., loss of strength and dexterity (motor coordination), mostly contribute to disability. Many factors may predict impairments in motor coordination (MC) and the identifications of these factors could help rehabilitation professionals to select variables to be considered in the evaluation and interventions aimed at improving MC of the lower limbs after stroke.

AIM

To investigate the potential predictors of motor coordination (MC) of the paretic lower limb with stroke subjects, as assessed by the Lower Limb Motor Coordination Test (LEMOCOT).

DESIGN

Cross-sectional, observational study.

SETTING

University laboratory.

POPULATION

One hundred and six stroke subjects.

METHODS

The selected potential predictors of the LEMOCOT scores were age, gender, motor recovery and sensation of the lower limb, tonus of the knee extensor and plantar flexor muscles, and strength of the hip flexor and knee flexor/extensor muscles. Step-wise multiple regression was employed for analysis.

RESULTS

Only motor recovery, tonus of the plantar flexor muscles, and age reached significance (P<0.05) and, consequently, were kept in the model. Motor recovery alone was able to explain 46% (F=89.0, P<0.001) of the variance in the LEMOCOT scores. When tonus of the plantar flexor muscles and age were included in the model, the explained variance increased to 54% (F=42.0, P<0.001). Lower limb motor recovery was positively associated with the LEMOCOT scores, whereas the tonus of the plantar flexor muscles and age were negatively correlated.

CONCLUSIONS

Motor recovery of the lower limb, tonus of the plantar flexor muscles, and age were significant predictors of MC of the paretic lower limb.

CLINICAL REHABILITATION IMPACT

These findings could help rehabilitation professionals to evaluate MC deficits and plan interventions aimed at improving MC of the lower limbs for stroke subjects, based upon the knowledge of the possible factors that could contribute to MC impairments.

Relationships between self-reported and performance-based measures of functional capacity in individuals with chronic stroke

[Purpose] The aim of this study was to investigate the associations between self-reported and valid performance-based measures of functional capacity in individuals with chronic stroke. [Subjects and Methods] Self-reported measures of functional capacity of 31 individuals with chronic stroke were assessed by the Duke Activity Status Index scores, whereas performance-based measures were assessed by the distance covered (in meters) and oxygen consumption (relative oxygen consumption, in ml·kg⁻¹·min⁻¹) during the six-minute walking test. [Results] The subjects had a mean age of 58.6±13 years and a mean time since the onset of stroke of 28.3±15.1 months. They had a mean Duke Activity Status Index of 27.3±14.4, mean distance covered of 325.2±140.2 m, and mean relative oxygen consumption of 9.6±2.3 ml·kg⁻¹·min⁻¹. Significant, positive, and moderate to good correlation coefficients were found between the Duke Activity Status Index scores and the distance covered during the six-minute walking test (r=0.68). Significant, positive, and fair associations were also found between the Duke Activity Status Index scores and relative oxygen consumption values obtained during the six-minute walking test (r=0.45). [Conclusion] The findings of the present study support the clinical use of the Duke Activity Status Index as a tool to assist in clinical evaluations of functional capacity of individuals with chronic stroke.

Assessment of the measurement properties of the post stroke motor function instruments available in Brazil: a systematic review

BACKGROUND

While there are several instruments in Brazil that measure motor function in patients after stroke, it is unknown whether the measurement properties of these instruments are appropriate.

OBJECTIVE

To identify the motor function instruments available in Brazil for patients after stroke. To assess the methodological quality of the studies and the results related to the measurement properties of these instruments.

METHOD

Two independent reviewers conducted searches on PubMed, LILACS, CINAHL, Web of Science, and Scopus. Studies that aimed to cross-culturally adapt an existing instrument or create a Brazilian instrument and test at least one measurement property related to motor function in patients after stroke were included. The methodological quality of these studies was checked by the COSMIN checklist with 4-point rating scale and the results of the measurement properties were analyzed by the criteria developed by Terwee et al.

RESULTS

A total of 11 instruments were considered eligible, none of which were created in Brazil. The process of cross-cultural adaptation was inadequate in 10 out of 11 instruments due to the lack of back-translation or due to inappropriate target population. All of the instruments presented flaws in the measurement properties, especially reliability, internal consistency, and construct validity.

CONCLUSION

The flaws observed in both cross-cultural adaptation process and testing measurement properties make the results inconclusive on the validity of the available instruments. Adequate procedures of cross-cultural adaptation and measurement properties of these instruments are strongly needed.

Prevention of Low Back Pain: A Systematic Review and Meta-analysis

IMPORTANCE

Existing guidelines and systematic reviews lack clear recommendations for prevention of low back pain (LBP).

OBJECTIVE

To investigate the effectiveness of interventions for prevention of LBP.

DATA SOURCES

MEDLINE, EMBASE, Physiotherapy Evidence Database Scale, and Cochrane Central Register of Controlled Trials from inception to November 22, 2014.

STUDY SELECTION

Randomized clinical trials of prevention strategies for nonspecific LBP.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed the risk of bias. The Physiotherapy Evidence Database Scale was used to evaluate the risk-of-bias. The Grading of Recommendations Assessment, Development, and Evaluation system was used to describe the quality of evidence.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was an episode of LBP, and the secondary outcome measure was an episode of sick leave associated with LBP. We calculated relative risks (RRs) and 95% CIs using random-effects models.

RESULTS

The literature search identified 6133 potentially eligible studies; of these, 23 published reports (on 21 different randomized clinical trials including 30,850 unique participants) met the inclusion criteria. With results presented as RRs (95% CIs), there was moderate-quality evidence that exercise combined with education reduces the risk of an episode of LBP (0.55 [0.41-0.74]) and low-quality evidence of no effect on sick leave (0.74 [0.44-1.26]). Low- to very low-quality evidence suggested that exercise alone may reduce the risk of both an LBP episode (0.65 [0.50-0.86]) and use of sick leave (0.22 [0.06-0.76]). For education alone, there was moderate- to very low-quality evidence of no effect on LBP (1.03 [0.83-1.27]) or sick leave (0.87 [0.47-1.60]). There was low- to very low-quality evidence that back belts do not reduce the risk of LBP episodes (1.01 [0.71-1.44]) or sick leave (0.87 [0.47-1.60]). There was low-quality evidence of no protective effect of shoe insoles on LBP (1.01 [0.74-1.40]).

CONCLUSION AND RELEVANCE

The current evidence suggests that exercise alone or in combination with education is effective for preventing LBP. Other interventions, including education alone, back belts, and shoe insoles, do not appear to prevent LBP. Whether education, training, or ergonomic adjustments prevent sick leave is uncertain because the quality of evidence is low.

Assessment of grip strength with the modified sphygmomanometer test: association between upper limb global strength and motor function

BACKGROUND

Grip strength, commonly evaluated with the handgrip dynamometer, is a good indicator of upper limb (UL) function in stroke subjects and may reflect the global strength deficits of the whole paretic UL. The Modified Sphygmomanometer Test (MST) also provides objective and adequate measures at low-cost.

OBJECTIVE

To assess whether grip strength values obtained by using the MST and those obtained by using a handgrip dynamometer would present similar correlations with the global strength and motor function of the paretic UL in subjects with stroke, both in the subacute and chronic phases.

METHOD

Measures of grip strength (MST and handgrip dynamometer), UL global strength (MST and hand-held dynamometer), and UL motor function (Fugl-Meyer motor assessment scale) were obtained with 33 subacute and 44 chronic stroke subjects. Pearson and Spearman correlation coefficients were calculated and Stepwise multiple regression analyses were performed to investigate predictor variables of grip strength (α=0.05).

RESULTS

Significant correlations of similar magnitude were found between measures of global strength of the paretic UL and grip strength assessed with both the MST (0.66≤r≤0.78) and handgrip dynamometer (0.66≤r≤0.78) and between UL motor function and grip strength assessed with both the MST (0.50≤rs≤0.51) and hand-held dynamometer (0.50≤rs≤0.63) in subacute and chronic stroke subjects. Only global strength remained as a significant predictor variable of grip strength for the MST (0.43≤R2≤0.61) and for the handgrip dynamometer (0.44≤R2≤0.61) for both stroke subgroups.

CONCLUSION

Grip strength assessed with the MST could be used to report paretic UL global strength.

Influences of hand dominance on the maintenance of benefits after home-based modified constraint-induced movement therapy in individuals with stroke

Objective:

To investigate the influence of hand dominance on the maintenance of gains after home-based modified constraint-induced movement therapy (mCIMT).

Method:

Aprevious randomized controlled trial was conducted to examine the addition of trunk restraint to the mCIMT. Twenty-two chronic stroke survivors with mild to moderate motor impairments received individual home-based mCIMT with or without trunk restraints, five times per week, three hours daily over two weeks. In this study, the participants were separated into dominant group, which had their paretic upper limb as dominant before the stroke (n=8), and non-dominant group (n=14) for analyses. The ability to perform unimanual tasks was measured by the Wolf Motor Function Test (WMFT) and the Motor Activity Log (MAL), whereas the capacity to perform bimanual tasks was measured using the Bilateral Activity Assessment Scale (BAAS).

Results:

Analysis revealed significant positive effects on the MAL amount of use and quality of the movement scales, as well as on the BAAS scores after intervention, with no differences between groups. Both groups maintained the bimanual improvements during follow-ups (BAAS-seconds 0.1, 95% CI -10.0 to 10.0), however only the dominant group maintained the unilateral improvements (MAL-amount of use: 1.5, 95% CI 0.7 to 2.3; MAL-quality: 1.3, 95% CI 0.5 to 2.1).

Conclusions:

Upper limb dominance did not interfere with the acquisition of upper limb skills after mCIMT. However, the participants whose paretic upper limb was dominant demonstrated better abilities to maintain the unilateral gains. The bilateral improvements were maintained, regardless of upper limb dominance.

Content validation of a clinical assessment instrument for stair ascent and descent in individuals with hemiparesis

BACKGROUND

Among the current instruments used to assess stair ambulation, none were observed that specifically evaluated the quality of movement or biomechanical strategies adopted by stroke patients.

OBJECTIVE

To evaluate the content validity of a clinical instrument designed to identify the qualitative and kinematic characteristics and strategies adopted by stroke patients during stair ascent and descent.

METHOD

The first developed version, which comprised 80 items, had its content evaluated by an expert panel, which was composed of 9 well-known national and international professionals who are involved in stroke rehabilitation. The content validity index (CVI) and modified Kappa coefficients were employed for the statistical analyses. The items that demonstrated a CVI≥0.80 and Kappa≥0.75 were considered valid.

RESULTS

The content validation was performed in three stages. The final version of the instrument consisted of 38 items, which were divided into descriptive (8 items), a General Characteristics Domain (16 items) and adopted strategies (14 items) during stair ascent and descent. The total scores ranged from zero to 70 and zero to 74 for ascent and descent, respectively. Lower scores corresponded with better performance.

CONCLUSION

Despite the satisfactory results obtained during the process of content validation, other psychometric properties of the instrument are necessary and must be evaluated.

Strength deficits of the shoulder complex during isokinetic testing in people with chronic stroke

OBJECTIVES

To examine the strength deficits of the shoulder complex after stroke and to characterize the pattern of weakness according to type of movement and type of isokinetic parameter.

METHOD

Twelve chronic stroke survivors and 12 age-matched healthy controls had their shoulder strength measured using a Biodex isokinetic dynamometer. Concentric measures of peak torque and work during shoulder movements were obtained in random order at speeds of 60°/s for both groups and sides. Type of movement was defined as scapulothoracic (protraction and retraction), glenohumeral (shoulder internal and external rotation) or combined (shoulder flexion and extension). Type of isokinetic parameter was defined as maximum (peak torque) or sustained (work). Strength deficits were calculated using the control group as reference.

RESULTS

The average strength deficit for the paretic upper limb was 52% for peak torque and 56% for work. Decreases observed in the non-paretic shoulder were 21% and 22%, respectively. Strength deficit of the scapulothoracic muscles was similar to the glenohumeral muscles, with a mean difference of 6% (95% CI -5 to 17). Ability to sustain torque throughout a given range of motion was decreased as much as the peak torque, with a mean difference of 4% (95% CI -2 to 10).

CONCLUSIONS

The findings suggest that people after stroke might benefit from strengthening exercises directed at the paretic scapulothoracic muscles in addition to exercises of arm elevation. Clinicians should also prescribe different exercises to improve the ability to generate force and the ability to sustain the torque during a specific range of motion.

Inspiratory muscular weakness is most evident in chronic stroke survivors with lower walking speeds

BACKGROUND

Respiratory muscular weakness and associated changes in thoracoabdominal motion have been poorly studied in stroke subjects, since the individuals' functional levels were not previously considered in the investigations.

AIM

To investigate the breathing patterns, thoracoabdominal motion, and respiratory muscular strength in chronic stroke subjects, who were stratified into two groups, according to their walking speeds.

DESIGN

Cross-sectional, observational study.

SETTING

University laboratory.

POPULATION

Eighty-nine community-dwelling chronic stroke subjects

METHODS

The subjects, according to their gait speeds, were stratified into community (gait speed ≥0.8 m/s) and non-community ambulators (gait speed <0.8 m/s). Variables related to pulmonary function, breathing patterns, and thoracoabdominal motions were assessed. Measures of maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were obtained and were compared with the reference values for the Brazilian population. The MIP and MEP values were expressed as percentages of the predicted values. Mann-Whitney-U or independent Student t-tests were employed to compare the differences between the two groups for the selected variables.

RESULTS

No significant between-group differences were found for the variables related to the breathing patterns and thoracoabdominal motions (0.01 < z/t < 1.51; 0.14<P<0.99). Compared to the predicted values, the stroke subjects demonstrated decreases of 26.5 and 20% of the MIP and MEP, respectively. Non-community ambulators showed significant lower predicted MIP values than those from the community ambulators (t=2.10; P=0.04). However, no significant between-group differences were found for the predicted MEP measures (t = -1.10; P=0.25).

CONCLUSION

Stroke subjects demonstrated weakness of the respiratory muscles and lower predicted MIP values were found for the non-community ambulators.

CLINICAL REHABILITATION IMPACT

Evaluations and interventions involving respiratory muscular training could be included in stroke rehabilitation, especially for individuals with lower functional levels.

Assessment of muscular strength with the modified sphygmomanometer test: what is the best method and source of outcome values?

Background

Tests that are usually employed for the clinical assessment of muscular strength have notable disadvantages. The Modified Sphygmomanometer Test (MST) is a promising method because it is low-cost and provides objective measures.

Objectives

To investigate the most adequate method and sources of outcome values for the assessment of strength with the MST.

Method

Methodological study with 40 healthy adults (22.98±2.26 years), who did not practice physical activity regularly. The strength of the flexors and extensors of the elbow and knee, the handgrip of the dominant side and anterior trunk flexors were randomly assessed with portable dynamometers and the MST (bag and cuff adaptations, and sphygmomanometer without adaptation) by a single examiner. An independent examiner read and recorded the values. The sources of the investigated outcome values were the first trial and the means of two and three trials. One-way ANOVAs and Pearson Correlation Coefficients were used for the analyses (α=0.05).

Results

For the MST methods applied to assess all muscular groups, similar values were found for all sources of outcome values (0.01<F<0.26; 0.77<p<1.00) with significant and positive correlations between the measures obtained with the dynamometers (0.51<r<0.94; p<0.003).

Conclusions

All MST methods showed adequate results for the assessment of strength in healthy individuals, and after familiarization, only one trial was sufficient to provide reliable measures. The sphygmomanometer without adaptation is not time consuming, compared to the other adaptations, and showed the capability of measuring higher values of strength. The bag method was easily trained to be used and stabilized.

Cyclical electrical stimulation increases strength and improves activity after stroke: a systematic review

QUESTION

Does electrical stimulation increase strength after stroke and are any benefits maintained beyond the intervention period or carried over to activity?

DESIGN

Systematic review with meta-analysis of randomised or controlled trials.

PARTICIPANTS

Adults who have had a stroke.

INTERVENTION

Cyclical electrical stimulation applied in order to increase muscle strength.

OUTCOME MEASURES

Strength measures had to be representative of maximum voluntary contraction and were obtained as continuous measures of force or torque, or ordinal measures such as manual muscle tests. Activity was measured using direct measures of performance that produced continuous or ordinal data, or with scales that produced ordinal data.

RESULTS

Sixteen trials representing 17 relevant comparisons were included in this systematic review. Effect sizes were calculated as standardised mean differences because various muscles were studied and different outcome measures were used. Overall, electrical stimulation increased strength by a standardised mean difference (SMD) of 0.47 (95% CI 0.26 to 0.68) and this effect was maintained beyond the intervention period (SMD 0.33, 95% CI 0.07 to 0.60). Electrical stimulation also improved activity (SMD 0.30, 95% CI 0.05 to 0.56) and this effect was also maintained beyond the intervention period (SMD 0.38, 95% CI 0.09 to 0.66).

CONCLUSION

Cyclical electrical stimulation increases strength and improves activity after stroke. These benefits were maintained beyond the intervention period with a small-to-moderate effect size. The sustained effect on activity suggests that the benefits were incorporated into daily life. Review registration: PROSPERO (CRD42013003895).

The addition of functional task-oriented mental practice to conventional physical therapy improves motor skills in daily functions after stroke

BACKGROUND

Mental practice (MP) is a cognitive strategy which may improve the acquisition of motor skills and functional performance of athletes and individuals with neurological injuries.

OBJECTIVE

To determine whether an individualized, specific functional task-oriented MP, when added to conventional physical therapy (PT), promoted better learning of motor skills in daily functions in individuals with chronic stroke (13 ± 6.5 months post-stroke).

METHOD

Nine individuals with stable mild and moderate upper limb impairments participated, by employing an A1-B-A2 single-case design. Phases A1 and A2 included one month of conventional PT, and phase B the addition of MP training to PT. The motor activity log (MAL-Brazil) was used to assess the amount of use (AOU) and quality of movement (QOM) of the paretic upper limb; the revised motor imagery questionnaire (MIQ-RS) to assess the abilities in kinesthetic and visual motor imagery; the Minnesota manual dexterity test to assess manual dexterity; and gait speed to assess mobility.

RESULTS

After phase A1, no significant changes were observed for any of the outcome measures. However, after phase B, significant improvements were observed for the MAL, AOU and QOM scores (p<0.0001), and MIQ-RS kinesthetic and visual scores (p=0.003; p=0.007, respectively). The significant gains in manual dexterity (p=0.002) and gait speed (p=0.019) were maintained after phase A2.

CONCLUSIONS

Specific functional task-oriented MP, when added to conventional PT, led to improvements in motor imagery abilities combined with increases in the AOU and QOM in daily functions, manual dexterity, and gait speed.

Treadmill training is effective for ambulatory adults with stroke: a systematic review

QUESTION

Does mechanically assisted walking increase walking speed or distance in ambulatory people with stroke compared with no intervention/non-walking intervention, or with overground walking?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Ambulatory adults with stroke.

INTERVENTION

Mechanically assisted walking (treadmill or gait trainer) without body weight support.

OUTCOME MEASURES

Walking speed measured in m/s during the 10-m Walk Test and walking distance measured in m during the 6-min Walk Test.

RESULTS

Nine studies of treadmill training comprising 977 participants were included. Treadmill training resulted in faster walking than no intervention/non-walking intervention immediately after the intervention period (MD 0.14m/s, 95% CI 0.09 to 0.19) and this was maintained beyond the intervention period (MD -0.12m/s, 95% CI 0.08 to 0.17). It also resulted in greater walking distance immediately after the intervention period (MD 40m, 95% CI 27 to 53) and this was also maintained beyond the intervention period (MD 40m, 95% CI 24 to 55). There was no immediate, statistically significant difference between treadmill training and overground training in terms of walking speed (MD 0.05m/s, 95% CI 0.12 to 0.21) or distance (MD -6m, 95% CI -45 to 33).

CONCLUSION

This systematic review provides evidence that, for people with stroke who can walk, treadmill training without body weight support results in faster walking speed and greater distance than no intervention/ non-walking intervention and the benefit is maintained beyond the training period.

Challenges in recruitment, attendance and adherence of acute stroke survivors to a randomized trial in Brazil: a feasibility study

BACKGROUND

There is a high demand for stroke rehabilitation in the Brazilian public health system which should make undertaking clinical trials straightforward.

OBJECTIVES

The aims of this study were to 1) determine the rate of recruitment of community-dwelling stroke survivors into a randomized trial of the effects of strength training in addition to task-specific gait training, 2) compare the effectiveness of various recruitment strategies on accrual rates, and 3) determine the attendance at training sessions and adherence to the intervention protocol.

METHODS

Participants within six months of a stroke were screened for eligibility and invited to participate. Recruitment strategies were classified as advertisement or referral. The number of people who were screened, eligible and recruited for each strategy was recorded. Attendance at training sessions and adherence to the intervention protocol were recorded.

RESULTS

Over the first 14 months, 150 stroke survivors were screened, 10 were recruited, and 35 (23%) were eligible. Twenty-five of these patients (71%) were unable to participate with lack of transport given as the most common reason. The most successful strategy was referral via hospital-based physical therapists (50%). Overall attendance was 72% with lack of transport being the most common reason for non-attendance. Overall adherence to the protocol was 97% with feeling unwell being the most common reason for non-adherence.

CONCLUSIONS

Recruitment of stroke survivors was inefficient. Lack of transport was the most common barrier to participate in and attend training sessions. Funding for transport is essential to make carrying out trials in Brazil feasible. Trial Registration ACTRN12609000803291.

Comparisons of the Nottingham Health Profile and the SF-36 health survey for the assessment of quality of life in individuals with chronic stroke

BACKGROUND

Appropriate instruments for the assessment of health-related quality of life (HRQOL) domains are useful for planning therapeutic interventions for individuals with stroke. The generic quality of life (QOL) instruments, Short Form Health Survey-36 (SF-36) and Nottingham Health Profile (NHP), have been frequently employed in the Brazilian literature. However, the literature is still scarce regarding their psychometric properties when applied to stroke individuals.

OBJECTIVES

To compare the Brazilian versions of the SF-36 and the NHP to verify which had better psychometric properties for the assessment of HRQOL in 120 individuals with chronic stroke.

METHOD

Spearman correlation coefficients were calculated to examine the comparable domains and total scores of the SF-36 and the NPH; Cronbach's alpha coefficients, to evaluate internal consistency; intra-class correlation coefficients, to assess reliability; and Bland-Altman plots, to assess the levels of agreement, with a significance level of 5%.

RESULTS

Significant positive associations were observed between the common domains and the total scores of the SF-36 and the NPH. Ceiling effects were more frequent for the NPH. The total scores of both instruments achieved adequate reliability levels, and the agreement levels were within the normal limits in 95% of the cases.

CONCLUSIONS

The SF-36 and the NPH were shown to measure similar constructs and proved to be useful measures for the assessment of QOL of chronic stroke subjects. However, the SF-36 yielded better results and appeared to be more appropriate.