Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke

Effects of intensive physical rehabilitation on neuromuscular adaptations in adults with poststroke hemiparesis

Hemiparesis-disability and muscle weakness of 1 side of the body-is a common consequence of stroke. High-intensity strength training may be beneficial to regain function, but strength coaches in the field of rehabilitation need evidence-based guidelines. The purpose of this study was to evaluate the effect of intensive physical rehabilitation on neuromuscular and functional adaptations in outpatients suffering from hemiparesis after stroke. A within-subject repeated-measures design with the paretic leg as the experimental leg and the nonparetic leg as the control leg was used. Eleven outpatients with hemiparesis after stroke participated in 12 weeks of intensive physical rehabilitation comprising unilateral high-intensity strength training with near-maximal loads (4-12 repetition maximum) and body weight supported treadmill training. At baseline and 12-week follow-up, the patients went through testing consisting of isokinetic muscle strength, neuromuscular activation measured with electromyography (EMG), electrically evoked muscle twitch contractile properties, and gait performance (10-m Walk Test and 6-min Walk Test). After the 12-week conditioning program, knee extensor and flexor strength increased during all contraction modes and velocities in the paretic leg. Significant increases were observed for agonist EMG amplitude at slow concentric and slow eccentric contraction. Twitch torque increased, whereas twitch time-to-peak tension remained unchanged. By contrast, no significant changes were observed in the nonparetic control leg. Gait performance increased 52-68%. In conclusion, intensive physical rehabilitation after stroke leads to clinically relevant neuromuscular improvements, leading to increased voluntary strength during a wide range of contraction modes and velocities, and improved gait velocity. Strength training coaches working in the field of rehabilitation can use this knowledge to safely and efficiently add high-intensity strength training to existing rehabilitation paradigms.

Characterizing walking activity in people with stroke

Stroke is the leading cause of disability in the U.S. Many people with stroke have limited walking ability and are inactive. In this paper we describe a novel shoe based sensor, SmartShoe, and a signal processing technique to identify walking activity. The technique was validated with 6 people with walking impairment due to stroke. The results suggest that the SmartShoe is able to accurately identify walking activity. This device could be used to monitor walking activity as well as provide behavioral enhancing feedback to increase activity levels and walking ability in people with stroke for extended periods of time in the real world.

Physical fitness training for stroke patients

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched April 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, July 2010), MEDLINE (1966 to March 2010), EMBASE (1980 to March 2010), CINAHL (1982 to March 2010), SPORTDiscus (1949 to March 2010), and five additional databases (March 2010). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both, with no intervention, a non-exercise intervention, or usual care in stroke survivors.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

[Therapeutic strategies in stroke aftercare. Contents and effects]

No generally accepted guidelines for stroke aftercare exist in Germany. This literature review summarizes the current evidence regarding the content and the effectiveness of aftercare strategies (exercise therapy, physiotherapy, occupational therapy) and their specific dose (intensity, duration, frequency). Exercise therapy (inter alia physiotherapy, resistance, endurance and gait training) has been shown to be effective for improving physical performance (strength, cardiopulmonary fitness, motor function) resulting in beneficial effects on gait, mobility and activities of daily living (ADL). As for the restoration of ADL and the resumption of social and leisure activities occupational therapy proved to be particularly effective. More research is needed to identify the specific effects of different aftercare strategies and their dose-response relationship to provide physicians a better foundation for therapy prescriptions.

rTMS Combined With Task-Oriented Training to Improve Symmetry of Interhemispheric Corticomotor Excitability and Gait Performance After Stroke

Background. The model of interhemispheric competition after stroke has been established for the upper but not for the lower extremity. Repetitive transcranial magnetic stimulation (rTMS) of the brain has been shown to modulate cortical excitability. Objective. The purpose of this study was to investigate the effects of rTMS followed by task-oriented training on cortical excitability and walking performance in individuals with chronic stroke. Methods. A total of 24 patients with average Fugl-Meyer lower limb scores of 17.88 ± 5.27 and average walking speeds of 63.81 ± 18.25 cm/s were randomized into an experimental group and a control group. Participants received rTMS (experimental group) or sham rTMS (control group) followed by task-oriented training (30 minutes) for 10 sessions over 2 weeks. Repetitive TMS was applied at a 1-Hz frequency over the leg area of the motor cortex of the unaffected hemisphere for 10 minutes. Outcomes, including motor-evoked potential (MEP), lower-extremity Fugl-Meyer score, and gait performance, were measured before and after training. Results. Decreased interhemispheric asymmetry of the amplitude of the MEP was noted after rTMS and task-oriented training. Improvement in spatial asymmetry of gait was comparable with increased symmetry in interhemispheric excitability. Motor control and walking ability were also significantly improved after rTMS and task-oriented training. Conclusions. rTMS enhances the effect of task-oriented training in those with chronic stroke, especially by increasing gait spatial symmetry and corticomotor excitability symmetry.

Effects of high-intensity resistance training on strength, mobility, balance, and fatigue in individuals with multiple sclerosis: a randomized controlled trial

BACKGROUND AND PURPOSE

Resistance exercise via negative, eccentrically induced work (RENEW) has been shown to be associated with improvements in strength, mobility, and balance in multiple clinical populations. However, RENEW has not been reported for individuals with multiple sclerosis (MS).

METHODS

Nineteen individuals with MS (8 men, 11 women; age mean = 49 ± 11 years; Expanded Disability Status Scale [EDSS] mean = 5.2 ± 0.9) were randomized into either standard exercise (STAND) or standard exercise and RENEW training (RENEW) for 3×/week for 12 weeks. Outcome measures were lower extremity strength (hip/knee flexion and extension, ankle plantar and dorsiflexion, and the sum of these individual values [sum strength]); Timed Up and Go (TUG), 10-m walk, self-selected pace (TMWSS) and maximal-pace (TMWMP), stair ascent (S-A) and descent (S-D) and 6-Minute Walk Test (6MWT), Berg Balance Scale (BBS), Fatigue Severity Scale (FSS).

RESULTS

No significant time effects or interactions were observed for strength, TUG, TMWSS, TMWMP, or 6MWT. However, the mean difference in sum strength in the RENEW group was 38.60 (representing a 15% increase) compared to the sum strength observed in the STAND group with a mean difference of 5.58 (a 2% increase). A significant interaction was observed for S-A, S-D, and BBS as the STAND group improved whereas the RENEW group did not improve in these measures.

DISCUSSION AND CONCLUSIONS

Contrary to results in other populations, the addition of eccentric training to standard exercises did not result in significantly greater lower extremity strength gains in this group of individuals with MS. Further this training was not as effective as standard exercise alone in improving balance or the ability to ascend and descend stairs. Following data collection, reassessment of required sample size indicates we were likely underpowered to detect strength differences between groups.

Automatic detection of temporal gait parameters in poststroke individuals

Approximately one-third of people who recover from a stroke require some form of assistance to walk. Repetitive task-oriented rehabilitation interventions have been shown to improve motor control and function in people with stroke. Our long-term goal is to design and test an intensive task-oriented intervention that will utilize the two primary components of constrained-induced movement therapy: massed, task-oriented training and behavioral methods to increase use of the affected limb in the real world. The technological component of the intervention is based on a wearable footwear-based sensor system that monitors relative activity levels, functional utilization, and gait parameters of affected and unaffected lower extremities. The purpose of this study is to describe a methodology to automatically identify temporal gait parameters of poststroke individuals to be used in assessment of functional utilization of the affected lower extremity as a part of behavior enhancing feedback. An algorithm accounting for intersubject variability is capable of achieving estimation error in the range of 2.6-18.6% producing comparable results for healthy and poststroke subjects. The proposed methodology is based on inexpensive and user-friendly technology that will enable research and clinical applications for rehabilitation of people who have experienced a stroke.

Skeletal muscle hypertrophy and muscle myostatin reduction after resistive training in stroke survivors

BACKGROUND AND PURPOSE

Stroke survivors experience disproportionate muscle atrophy and other detrimental tissue composition changes on the paretic side. The purpose was to determine whether myostatin levels are higher in paretic vs nonparetic muscle and the effects of resistive training (RT) on paretic and nonparetic mid-thigh muscle composition and myostatin mRNA expression in stroke survivors.

METHODS

Fifteen stroke survivors (50-76 years) underwent bilateral multi-slice thigh CT scanning from the knee to the hip, bilateral vastus lateralis skeletal muscle tissue biopsies, a total body scan by dual-energy X-ray absorptiometry, and 1-repetition maximum strength test before and after a 12-week, (3 times/week) RT intervention.

RESULTS

Total body fat mass and fat-free mass did not change. Bilateral leg press and leg extension 1-repetition maximum strength increased 31% to 56% with RT (P<0.001). Paretic and nonparetic muscle area of the mid-thigh increased 13% (P<0.01) and 9% (P<0.05), respectively, after RT. Muscle attenuation of the mid-thigh increased 15% and 8% (both P<0.01) in the paretic and nonparetic thigh, respectively, representing reduced intramuscular fat. Muscle volume increased 14% (P<0.001) in the paretic thigh and 16% (P<0.05) in the nonparetic thigh after RT. Myostatin mRNA expression levels were 40% higher in the paretic than nonparetic muscle (P=0.001) at baseline and decreased 49% in the paretic muscle (P<0.005) and 27% in the nonparetic muscle (P=0.06) after RT.

CONCLUSIONS

Progressive RT stimulates significant muscle hypertrophy and intramuscular fat reductions in disabled stroke survivors. The increased myostatin mRNA in the paretic thigh and reduction with RT imply an important regulatory role for myostatin after stroke.

Feasibility and effectiveness of circuit training in acute stroke rehabilitation

BACKGROUND

Task-specificity, repetition and progression are key variables in the acquisition of motor skill however they have not been consistently implemented in post-stroke rehabilitation.

OBJECTIVE

To evaluate the effectiveness of a stroke rehabilitation plan of care that incorporated task-specific practice, repetition and progression to facilitate functional gain compared to standard physical therapy for individuals admitted to an inpatient stroke unit.

METHODS

Individuals participated in either a circuit training (CTPT) model (n = 72) or a standard (SPT) model (n = 108) of physical therapy, 5 days/week. Each 60 minute circuit training session, delivered according to severity level, consisted of four functional mobility tasks. Daily exercise logs documented both task repetition and progression.

RESULTS

The CTPT model was successfully implemented in an acute rehabilitation setting. The CTPT group showed a significantly greater improved change in gait speed from hospital admission to discharge than the SPT group (0.21 ± 0.25 m/sec vs. 0.13 ± 0.22 m/sec; p = 0.03). The difference between groups occurred primarily among those who were ambulatory upon admission. There were no significant differences between the two cohorts at 90 days post-stroke as measured by the FONE-FIM, SF-36 and living location.

CONCLUSIONS

Therapy focused on systematically progressed functional tasks can be successfully implemented in an inpatient rehabilitation stroke program. This circuit-training model resulted in greater gains in gait velocity over the course of inpatient rehabilitation compared to the standard model of care. Community-based services following hospital discharge to maintain these gains should be included in the continuum of post-stroke care.

Circuit class therapy for improving mobility after stroke

BACKGROUND

Circuit class therapy (CCT) offers a supervised group forum for people after stroke to practise tasks, enabling increased practise time without increasing staffing.

OBJECTIVES

To examine the effectiveness and safety of CCT on mobility in adults with stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched October 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2009), MEDLINE (1950 to November 2008), EMBASE (1980 to November 2008), CINAHL (1982 to November 2008) and 14 other electronic databases (to November 2008). We also searched proceedings from relevant conferences, reference lists and unpublished theses; contacted authors of published trials and other experts in the field; and searched relevant clinical trials and research registers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials including people over 18 years old diagnosed with stroke of any severity, at any stage, or in any setting, receiving CCT.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed methodological quality and extracted data.

MAIN RESULTS

We included six trials involving 292 participants. Participants were long-term stroke survivors living in the community or receiving inpatient rehabilitation. All could walk 10 metres with or without assistance. Four studies measured walking capacity and three measured gait speed, demonstrating that CCT was superior to the comparison intervention (Six Minute Walk Test: mean difference (MD), fixed 76.57 metres, 95% confidence interval (CI) 38.44 to 114.70, P < 0.0001; gait speed: MD, fixed 0.12 m/s, 95% CI 0.00 to 0.24, P = 004). Two studies measured balance, showing a superior effect in favour of CCT (Step Test: MD, fixed 3.00 steps, 95% CI 0.08 to 5.91, P = 0.04; activities-specific balance and confidence: MD, fixed 7.76, 95% CI 0.66 to 14.87, P = 0.03). Studies also measured other balance items showing no difference in effect. Length of stay (two studies) showed a significant effect in favour of CCT (MD, fixed -19.73 days, 95% CI -35.43 to -4.04, P = 0.01). Only two studies measured adverse events (falls during therapy): all were minor.

AUTHORS' CONCLUSIONS

CCT is safe and effective in improving mobility for people after moderate stroke and may reduce inpatient length of stay. Further research is required, investigating quality of life, participation and cost-benefits, that compares CCT to standard care and that also investigates the differential effects of stroke severity, latency and age.

Treinamento de marcha, cardiorrespiratório e muscular após acidente vascular encefálico: estratégias, dosagens e desfechos

INTRODUÇÃO: Um número crescente de programas de treinamento com resultados positivos tem sido proposto para a reabilitação de pacientes com sequelas motoras após acidente vascular encefálico (AVE). No entanto, observa-se que muitos não oferecem recomendações no que diz respeito a indicações para técnicas e procedimentos específicos. OBJETIVO: Revisar a literatura pertinente sobre programas de treinamento envolvendo marcha, condicionamento cardiorrespiratório e fortalecimento muscular de membros inferiores em pacientes portadores de hemiparesia por sequela de AVE, e descrever a eficácia, limitações e efeitos desses programas na recuperação cardiovascular, funcional e motora dessa população. MÉTODO: Foi realizada uma busca por ensaios clínicos, trabalhos pré-experimentais, meta-análises e revisões de literatura que abordassem os temas treinamento físico, fortalecimento muscular, treinamento de marcha e programas de exercícios para membros inferiores após AVE. RESULTADOS: Foram encontrados 27 artigos relatando diversos protocolos de treinamento (marcha, treinamento cardiovascular, fortalecimento muscular, entre outros) e seus efeitos no sistema cardiovascular, músculo-esquelético e sobre o status funcional em indivíduos portadores de hemiparesia após AVE. CONCLUSÃO: Praticamente todas as intervenções relatam resultados positivos em termos de ganhos funcionais, além de efeitos específicos de acordo com o tipo de treinamento. No entanto, as diferenças metodológicas, a carência de grupo controle em alguns estudos, a variabilidade da população estudada e os critérios de análise nem sempre permitem a recomendação segura de procedimentos específicos na prática clínica.

Effects of combining electric stimulation with active ankle dorsiflexion while standing on a rocker board: a pilot study for subjects with spastic foot after stroke

OBJECTIVE

To investigate the therapeutic effects of combining electric stimulation (ES) with active ankle dorsiflexion while standing on a rocker board in subjects with plantarflexor spasticity after stroke.

DESIGN

Randomized controlled trial.

SETTING

A rehabilitation medical center.

PARTICIPANTS

Subjects (N=15) with spastic foot after stroke.

INTERVENTIONS

Subjects were randomly assigned to an experimental or a control group. The experimental group received ES of ankle dorsiflexors in concert with a motor training paradigm that required the subject to dorsiflex the ankles in response to a cue while standing on a rocker board. After 30 minutes of this exercise, subjects received ambulation training focusing on ankle control for 15 minutes. The control group received general range of motion and strength exercises for 30 minutes, followed by 15 minutes of ambulation training focusing on ankle control. Sessions occurred 3 times a week for 4 weeks.

MAIN OUTCOME MEASURES

Dynamic spasticity of plantarflexors, dorsiflexor muscle strength, balance performance, gait kinematics, and functional gait performance as assessed by the Emory Functional Ambulation Profile (EFAP) were used as outcome measurements.

RESULTS

The experimental group demonstrated a greater decrease in dynamic ankle spasticity at a comfortable gait speed (P=.049), a greater improvement in spatial gait symmetry (P=.015), and a greater improvement in functional gait ability as indicated by the EFAP (P=.015) than the control group.

CONCLUSIONS

Our results suggest that repeated ES with volitional ankle movements can decrease dynamic ankle spasticity in subjects with stroke. Furthermore, such improvement parallels better gait symmetry and functional gait performance.

Effectiveness of a community-based low intensity exercise programme for ambulatory stroke survivors

PURPOSE

To establish the feasibility and effectiveness of a community-based exercise programme for ambulatory patients with stroke discharged from rehabilitation.

METHOD

Eighteen participants were recruited 3-12 months after onset of first stroke. Using a time series experimental design, the group completed a baseline period of 4 weeks (A1), a group exercise programme of low-intensity progressive resistive exercise and functional tasks for lower limb muscles (B) and repeat assessment after cessation of exercise (A2). Fitness instructors delivered sessions at Leisure Centres twice weekly for 14 weeks with physiotherapy support and the minimum attendance requirement was 16 sessions. Measures included muscle strength, gait velocity, Berg Balance Scale and Nottingham Extended Activities of Daily Living.

RESULTS

Lower limb muscle strength improved after training (ANOVA, p < 0.02). Paretic knee extension strength increased from 43.4 + or - 5.9 to 60.4 + or - 6.8 Nm after 16 exercise sessions. Walking velocity increased significantly (ANOVA, p < 0.001), from 0.54 + or - 0.07 to 0.75 + or - 0.08 m/s (t = -3.31, p < 0.01). Balance and everyday function were also significantly improved (p < 0.003). There were marked individual variation in the response to training, and those who completed additional training did not show benefit.

CONCLUSIONS

This community-based exercise programme was feasible and delivered positive improvements in physical function for participants. Further issues raised for investigation include the individual response to training and the benefits of extended training.

Automatic recognition of postures and activities in stroke patients

Stroke is the leading cause of disability in the United States. It is estimated that 700,000 people in the United States will experience a stroke each year and that there are over 5 million Americans living with a stroke. In this paper we describe a novel methodology for automatic recognition of postures and activities in patients with stroke that may be used to provide behavioral enhancing feedback to patients with stroke as part of a rehabilitation program and potentially enhance rehabilitation outcomes. The recognition methodology is based on Support Vector classification of the sensor data provided by a wearable shoe-based device. The proposed methodology was validated in a case study involving an individual with a chronic stroke with impaired motor function of the affected lower extremity and impaired walking ability. The results suggest that recognition of postures and activities may be performed with very high accuracy.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Physical fitness training for stroke patients

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Motor recovery after stroke: a systematic review

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

Dampace: Design of an Exoskeleton for Force-Coordination Training in Upper-Extremity Rehabilitation

The Dampace exoskeleton combines functional exercises resembling activities of daily living with impairment-targeted force-coordination training. The goal of this paper is to evaluate the performance of the Dampace. In the design, the joint rotations are decoupled from the joint translations; the robot axes align themselves to the anatomical axes, overcoming some of the traditional difficulties of exoskeletons. Setup times are reduced to mere minutes and static reaction forces are kept to a minimum. The Dampace uses hydraulic disk brakes, which can resist rotations with up to 50 N m and have a torque bandwidth of 10 Hz for multisine torques of 20 N m. The brakes provide passive control over the movement; the patients’ movements can be selectively resisted, but active movement assistance is impossible and virtual environments are restricted. However, passive actuators are inherently safe and force active patient participation. In conclusion, the Dampace is well suited to offer force-coordination training with functional exercises.

Efficacy of Functional Strength Training on Restoration of Lower-Limb Motor Function Early After Stroke: Phase I Randomized Controlled Trial

After stroke, physiotherapy can promote brain reorganization and motor recovery. Combining muscle strength and functional training (functional strength training, FST) may be beneficial. The aim of the authors was to compare FST with conventional physiotherapy (CPT) while controlling for the potential confounder of therapy intensity in a multicenter, randomized controlled observer-blind trial. The mean age of the participants was 68.3 (standard deviation [SD] = 12.03) years at a mean of 34 (SD = 20) days after stroke, with mean peak paretic knee extension torque (torque) of 22 (SD = 25) Nm. The estimated sample size was 102 to detect a between-group difference of 0.2 m/s in walking speed. After baseline measures, participants were allocated randomly to CPT or CPT + CPT or CPT + FST for 6 weeks. Additional experimental therapy was provided for up to 1 hour a day, 4 times each week. Outcomes were measured 6 weeks after baseline and at follow-up 12 weeks thereafter. Measures included walking speed, knee extensor torque, and functional mobility (Rivermead). At outcome, both extraintensity groups showed greater increases in walking speed than the CPT group, but this reached significance only for the CPT + CPT group ( P = .031). The CPT + CPT group also had a greater number of participants who walked at 0.8 m/s or above. No significant differences were observed for torque about the knee or for the Rivermead score. At follow-up, no significant differences were observed. These phase I results justify a subsequent trial of CPT + CPT versus CPT + FST.

Clinical outcome measures in spinal muscular atrophy

Spinal muscular atrophy is one of the most devastating neurological diseases of childhood. Affected infants and children suffer from often severe muscle weakness caused by degeneration of lower motor neurons in the spinal cord and brainstem. Identification of the causative genetic mutation in most cases has resulted in development of potential treatment strategies. To test these new drugs, clinically feasible outcomes are needed. Several different assessments, validated in spinal muscular atrophy or similar disorders, are being used by national and international research groups; however, their sensitivity to detect change is unknown. Acceptance of a few standardized, easily administered, and functionally meaningful outcomes, applicable to the phenotypic spectrum of spinal muscular atrophy, is needed. Consensus is imperative to facilitate collaboration and explore the ability of these measures to identify the therapeutic effect of disease-modifying agents. Following is an evidence-based review of available clinical outcome measures in spinal muscular atrophy.

Overground physical therapy gait training for chronic stroke patients with mobility deficits

BACKGROUND

Overground gait training forms a major part of physical therapy services for chronic stroke patients in almost every setting. Overground gait training refers to physical therapists' observation and cueing of the patient's walking pattern along with related exercises, but does not include high-technology aids such as functional electrical stimulation or body weight support.

OBJECTIVES

To assess the effects of overground physical therapy gait training on walking ability for chronic stroke patients with mobility deficits.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched March 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2008), MEDLINE (1966 to May 2008), EMBASE (1980 to May 2008), CINAHL (1982 to May 2008), AMED (1985 to March 2008), Science Citation Index Expanded (1981 to May 2008), ISI Proceedings (Web of Science, 1982 to May 2006), Physiotherapy Evidence Database (http://www.pedro.org.au/) (May 2008), REHABDATA (http://www.naric.com/research/rehab/) (1956 to May 2008), http://www.clinicaltrials.gov (May 2008), http://www.controlled-trials.com/ (May 2008), and http://www.strokecenter.org/ (May 2008). We also searched reference lists of relevant articles, and contacted authors and trial investigators.

SELECTION CRITERIA

Randomised controlled trials comparing overground physical therapy gait training with a placebo intervention or no treatment for chronic stroke patients with mobility deficits.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently selected trials. Three authors independently extracted data and assessed quality. We contacted study authors for additional information.

MAIN RESULTS

We included nine studies involving 499 participants. We found no evidence for a benefit on the primary variable, post-test gait function, based on three studies with 269 participants. Uni-dimensional performance variables did show significant effects post-test. Gait speed increased by 0.07 metres per second (95% confidence interval (CI) 0.05 to 0.10) based on seven studies with 396 participants, timed up-and-go (TUG) test improved by 1.81 seconds (95% CI -2.29 to -1.33), and six-minute-walk test (6MWT) increased by 26.06 metres (95% CI 7.14 to 44.97) based on four studies with 181 participants. We found no significant differences in deaths/disabilities or in adverse effects, based on published reports or personal communication from all of the included studies.

AUTHORS' CONCLUSIONS

We found insufficient evidence to determine if overground physical therapy gait training benefits gait function in patients with chronic stroke, though limited evidence suggests small benefits for uni-dimensional variables such as gait speed or 6MWT. These findings must be replicated by large, high quality studies using varied outcome measures.

Progressive resistance strength training for improving physical function in older adults

BACKGROUND

Muscle weakness in old age is associated with physical function decline. Progressive resistance strength training (PRT) exercises are designed to increase strength.

OBJECTIVES

To assess the effects of PRT on older people and identify adverse events.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (to March 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to May 01, 2008), EMBASE (1980 to February 06 2007), CINAHL (1982 to July 01 2007) and two other electronic databases. We also searched reference lists of articles, reviewed conference abstracts and contacted authors.

SELECTION CRITERIA

Randomised controlled trials reporting physical outcomes of PRT for older people were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed trial quality and extracted data. Data were pooled where appropriate.

MAIN RESULTS

One hundred and twenty one trials with 6700 participants were included. In most trials, PRT was performed two to three times per week and at a high intensity. PRT resulted in a small but significant improvement in physical ability (33 trials, 2172 participants; SMD 0.14, 95% CI 0.05 to 0.22). Functional limitation measures also showed improvements: e.g. there was a modest improvement in gait speed (24 trials, 1179 participants, MD 0.08 m/s, 95% CI 0.04 to 0.12); and a moderate to large effect for getting out of a chair (11 trials, 384 participants, SMD -0.94, 95% CI -1.49 to -0.38). PRT had a large positive effect on muscle strength (73 trials, 3059 participants, SMD 0.84, 95% CI 0.67 to 1.00). Participants with osteoarthritis reported a reduction in pain following PRT(6 trials, 503 participants, SMD -0.30, 95% CI -0.48 to -0.13). There was no evidence from 10 other trials (587 participants) that PRT had an effect on bodily pain. Adverse events were poorly recorded but adverse events related to musculoskeletal complaints, such as joint pain and muscle soreness, were reported in many of the studies that prospectively defined and monitored these events. Serious adverse events were rare, and no serious events were reported to be directly related to the exercise programme.

AUTHORS' CONCLUSIONS

This review provides evidence that PRT is an effective intervention for improving physical functioning in older people, including improving strength and the performance of some simple and complex activities. However, some caution is needed with transferring these exercises for use with clinical populations because adverse events are not adequately reported.

An evaluation of two different exercise regimes during the first year following stroke: a randomised controlled trial

The purpose of this randomised controlled trial was to evaluate the effects of two different exercise approaches during the first 12 months post stroke on Instrumental Activities of Daily Living (IADL), motor function, gait performance, balance, grip strength, and muscle tone. This study is a double-blind longitudinal randomised trial of first-time-ever stroke patients. Seventy-five patients were included: 35 in an intervention group and 40 in a self-initiated exercise group. After discharge from acute rehabilitation, patients assigned in the intervention group had physiotherapy for a minimum amount of 80 hours during the first year. Patients in the self-initiated exercise group were not recommended any specific therapy besides treatment when needed. Main outcome measures were Instrumental Activities of Daily Living according to Fillenbaum, Motor Assessment Scale, 6-Minute Walk Test, Berg Balance Scale, Timed Up-and-Go Test, grip strength, Modified Ashworth Scale, and pulse monitoring. The patients were tested on admission, at discharge, and after 3, 6, and 12 months post stroke by an experienced investigator, blinded to group assignment. Twelve months post stroke showed higher levels of independence in all items of the Instrumental Activities of Daily Living Test and improvements in the results of Motor Assessment Scale, 6-Minute Walk Test, Berg Balance Scale, Timed Up-and-Go, and grip strength in both groups. Only a few significant differences were seen between groups, and they were in favour of the self-initiated exercise group (e.g., ability to use the telephone independently). Attending examination sessions following each intervention phase appeared to be strong motivators for training, irrespective of group allocation.

Task-oriented training in rehabilitation after stroke: systematic review

AIM

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

BACKGROUND

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

Lower-extremity strength differences predict activity limitations in people with chronic stroke

BACKGROUND

Body system impairments following stroke have a complex relationship with functional activities. Although gait and balance deficits are well-documented in people after stroke, the overlapping influence of body impairments makes it difficult to prioritize interventions.

OBJECTIVE

This study examined the relationship between prospectively selected measures of body function and structure (body mass index, muscle strength, sensation, and cognition) and activity (gait speed, gait endurance, and functional balance) in people with chronic stroke.

DESIGN

This was a cross-sectional, observational study.

METHODS

Twenty-six individuals with mean (SD) age of 57.6 (11) years and time after stroke of 45.4 (43) months participated. Four variables (body mass index, muscle strength difference between the lower extremities, sensation difference between the lower extremities, and Mini-Mental Status Exam score) were entered into linear regression models for gait speed, Six-Minute Walk Test distance, and Berg Balance Scale score.

RESULTS

Lower-extremity strength difference was a significant individual predictor for gait speed, gait endurance, and functional balance. Cognition significantly predicted only gait speed.

LIMITATIONS

The authors did not include all possible factors in the model that may have influenced gait and balance in these individuals.

CONCLUSIONS

Strength deficits in the hemiparetic lower extremity should be an important target for clinical interventions to improve function in people with chronic stroke.

Bilateral upper limb training with functional electric stimulation in patients with chronic stroke

BACKGROUND

The recovery rate of upper limb function after stroke is poor when compared with independent walking. Therefore, effective methods are warranted for upper limb rehabilitation.

OBJECTIVE

The aim of this study was to investigate the effectiveness of functional electric stimulation (FES) with bilateral activities training on upper limb function.

METHODS

This study was a double-blinded randomized controlled trial. Twenty patients were recruited 6 months after the onset of stroke and completed 15 training sessions. Participants were randomly assigned to the FES group or to the control group. Each session consisted of stretching activities (10 minutes), FES with bilateral tasks (20 minutes), and occupational therapy treatment (60 minutes). The participants used a self-trigger mechanism, with an accelerometer as a motion detector, for generating an electric stimulation pattern that was synchronized with the bilateral upper limb activities during the training. The participants in the control group received the same duration of stretching and occupational therapy training except that they just received placebo stimulation with the bilateral tasks. The outcome measures included Functional Test for the Hemiplegic Upper Extremity (FTHUE), Fugl-Meyer Assessment (FMA), grip power, forward reaching distance, active range of motion of wrist extension, Functional Independence Measure, and Modified Ashworth Scale.

RESULTS

At baseline comparison, there was no significant difference in both groups. After 15 training sessions, the FES group had significant improvement in FMA (P = .039), FTHUE (P = .001), and active range of motion of wrist extension (P = .020) when compared with the control group.

CONCLUSIONS

Bilateral upper limb training with FES could be an effective method for upper limb rehabilitation of stroke patients after 15 training sessions.

Effects of Conventional Physical Therapy and Functional Strength Training on Upper Limb Motor Recovery After Stroke: A Randomized Phase II Study

Background. Functional training and muscle strength training may improve upper limb motor recovery after stroke. Combining these as functional strength training (FST) might enhance the benefit, but it is unclear whether this is better than conventional physical therapy (CPT). Comparing FST with CPT is not straightforward. Objective. This study aimed at assessing the feasibility of conducting a phase III trial comparing CPT with FST for upper limb recovery. Methods. Randomized, observer-blind, phase II trial. Subjects had upper limb weakness within 3 months of anterior circulation infarction. Subjects were randomized to CPT (no extra therapy), CPT + CPT, and CPT + FST. Intervention lasted 6 weeks. Primary outcome measure was the Action Research Arm Test (ARAT). Measurements were taken before treatment began, after 6 weeks of intervention, and 12 weeks thereafter. Attrition rate was calculated and differences between groups were interpreted using descriptive statistics. ARAT data were used to inform a power calculation. Results. Thirty subjects were recruited (8% of people screened). Attrition rate was 6.7% at outcome and 40% at follow-up. At outcome the CPT + FST group showed the largest increase in ARAT score and this was above the clinically important level of 5.7 points. Median (interquartile range) increases were 11.5 (21.0) for CPT; 8.0 (13.3) for CPT + CPT; and 19.5 (22.0) for CPT + FST. The estimated sample size for an adequately powered subsequent phase III trial was 279 subjects at outcome. Conclusion. Further work toward a phase III clinical trial appears justifiable.

Does functional strength training of the leg in subacute stroke improve physical performance? A pilot randomized controlled trial

Objective: To examine the effect of functional strength training in subacute stroke.

Design: A single-blinded randomized controlled trial.

Setting: Two rehabilitation units.

Subjects: Eighteen patients in the subacute phase post stroke, randomly allocated to a functional strength training (intervention) group (n = 8) and a training-as-usual (comparison) group (n = 10).

Intervention: The functional strength training group participated in functional progressive strength training of the affected lower extremity. The training-as-usual group had traditional training, excessive muscle power being avoided to prevent associated reactions. All trained 50 minutes five days a week for four weeks.

Main measures: Maximum weight-bearing in standing (primary outcome), isometric muscle strength, gait speed and items of Motor Assessment Scale.

Results: Maximum weight-bearing on the affected leg improved more in the functional strength training group (mean 17.4% of body weight) than in the training-as-usual group (mean 5.6% of body weight), but taking test data at inclusion into consideration, the difference in change was not statistically significant (P = 0.056). More patients in the functional strength training group (57%) could weight-bear on the affected leg while stepping forward, than in the training-as-usual group (17%). Improvement was clinically significant in 7 of 9 outcome measures in the functional strength training group (effect size ≥0.80, large), but in only 3 of 9 in the training-as-usual group. All patients in the functional strength training group and 70% of the patients in the training-as-usual group rated their overall status as `much' or `very much' improved.

Conclusions: This pilot study indicates that functional strength training of lower extremities improves physical performance more than traditional training.

Intrinsic muscle strength and voluntary activation of both lower limbs and functional performance after stroke

The objective of this study was to assess the nature of muscle weakness in both legs after stroke compared with able-bodied control individuals and to examine whether there is a relationship between the degree of muscle weakness and coactivation of knee extensors and flexors as well as voluntary activation capacity of knee extensors of both paretic and non-paretic legs and indices of functional performance. Maximal voluntary isometric torques of knee extensors (MVCe) and flexors (MVCf) were determined in 14 patients (bilaterally) and 12 able-bodied controls. Simultaneous measurements were made of torque and surface EMG from agonist and antagonist muscles. Coactivation was calculated. Supramaximal triplets were evoked with electrical stimulation to estimate maximal torque capacity and degree of voluntary activation of knee extensors. MVCs, activation and coactivation parameters were correlated to scores of seven functional performance tests. MVCe, MVCf and voluntary activation were lower in paretic lower limb (PL) compared with both non-paretic lower limb (NL) and control. Besides, all these parameters of NL were also lower than control. Electrically evoked torque capacity of knee extensors of PL was about 60% of both NL and control, which were not significantly different from each other. Strong significant correlations between strength, as well as voluntary activation, and functional performance were found. Coactivation did not correlate well with functional performance. Thus, whereas for NL activation failure can explain weakness, for PL both activation failure and reduced intrinsic torque capacity are responsible for the severe weakness. Activation capacity and muscle strength correlated strongly to functional performance, while coactivation did not.

Skeletal muscle changes after hemiparetic stroke and potential beneficial effects of exercise intervention strategies

Stroke is the leading cause of disability in the United States. New evidence reveals significant structural and metabolic changes in skeletal muscle after stroke. Muscle alterations include gross atrophy and shift to fast myosin heavy chain in the hemiparetic (contralateral) leg muscle; both are related to gait deficit severity. The underlying molecular mechanisms of this atrophy and muscle phenotype shift are not known. Inflammatory markers are also present in contralateral leg muscle after stroke. Individuals with stroke have a high prevalence of insulin resistance and diabetes. Skeletal muscle is a major site for insulin-glucose metabolism. Increasing evidence suggests that inflammatory pathway activation and oxidative injury could lead to wasting, altered function, and impaired insulin action in skeletal muscle. The health benefits of exercise in disabled populations have now been recognized. Aerobic exercise improves fitness, strength, and ambulatory performance in subjects with chronic stroke. Therapeutic exercise may modify or reverse skeletal muscle abnormalities.

Gait training strategies to optimize walking ability in people with stroke: a synthesis of the evidence

Stroke is a leading cause of long-term disability. Impairments resulting from stroke lead to persistent difficulties with walking and, subsequently, improved walking ability is one of the highest priorities for people living with a stroke. In addition, walking ability has important health implications in providing protective effects against secondary complications common after a stroke such as heart disease or osteoporosis. This paper systematically reviews common gait training strategies (neurodevelopmental techniques, muscle strengthening, treadmill training and intensive mobility exercises) to improve walking ability. The results (descriptive summaries as well as pooled effect sizes) from randomized controlled trials are presented and implications for optimal gait training strategies are discussed. Novel and emerging gait training strategies are highlighted and research directions proposed to enable the optimal recovery and maintenance of walking ability.

Repetitive task training for improving functional ability after stroke

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

PRIMARY OUTCOMES

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

SECONDARY OUTCOMES

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

AUTHORS' CONCLUSIONS

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

Dual-Task Exercise Improves Walking Ability in Chronic Stroke: A Randomized Controlled Trial

OBJECTIVE

To examine the effectiveness of a dual-task-based exercise program on walking ability in subjects with chronic stroke.

DESIGN

Single-blind randomized controlled trial.

SETTING

General community.

PARTICIPANTS

Twenty-five subjects with chronic stroke who were at least limited community ambulatory subjects (a minimum gait velocity, 58cm/s).

INTERVENTIONS

Participants were randomized into a control group (n=12) or experimental group (n=13). Subjects in the control group did not receive any rehabilitation training. Subjects in the experimental group underwent a 4-week ball exercise program.

MAIN OUTCOME MEASURES

Gait performance was measured under single task (preferred walking) and tray-carrying task. Gait parameters of interest were walking speed, cadence, stride time, stride length, and temporal symmetry index.

RESULTS

The experimental group showed significant improvement in all selected gait measures except for temporal symmetry index under both task conditions. In the control group, there were no significant changes over the 4-week period for all selected measures. There was a significant difference between groups for all selected gait variables except for temporal symmetry index under both task conditions.

CONCLUSIONS

The dual-task-based exercise program is feasible and beneficial for improving walking ability in subjects with chronic stroke.

Circuit training in community-living "younger" men after stroke

OBJECTIVES

We sought to assess a training program focused on muscle strength and endurance in persons with prior stroke.

METHODS

Thirty men with a slight hemiparesis caused by a first occurrence of stroke at least 6 months earlier were included with an average age of 54 years. The following was assessed before and after an 8-week period: muscle strength, endurance, work capacity, and activity level. The training group consisted of 21 persons and 9 served as control subjects. There were no differences between the groups in the various assessments from the start. The training was set up as circuit training with 5 stations aiming to strengthen the muscles and increase endurance in the bilateral lower limbs. The session lasted for 45 minutes, 3 times per week, for 8 weeks. On eligible persons in the training group, double-sided muscle biopsies were also performed before and after.

RESULTS

There was significance in improved muscle strength and improved peak oxygen uptake for the paretic leg, which was reflected in the muscle enzymes. The nonparetic side also showed improvement, but to a lesser extent. The control group remained unchanged.

CONCLUSIONS

Stroke survivors can improve muscle strength, endurance, and work capacity in both the paretic and nonparetic leg with a circuit training program.