A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke

Additional task-related practice improves mobility and upper limb function early after stroke: A randomised controlled trial

The purpose of this study was to investigate whether additional practice of either upper limb or mobility tasks improved functional outcome during inpatient stroke rehabilitation. This prospective, randomised, single blind clinical trial recruited 30 stroke subjects into either an Upper Limb or a Mobility Group. All subjects received their usual rehabilitation and an additional session of task-related practice using a circuit class format. Independent assessors, blinded to group allocation, tested all subjects. Outcome measures used were three items of the Jebsen Taylor Hand Function Test (JTHFT), two arm items of the Motor Assessment Scale (MAS), and three mobility measures, the Timed Up and Go Test (TUGT), Step Test, and Six Minute Walk Test (6MWT). Both groups improved significantly between pre- and post-tests on all of the mobility measures, however only the Upper Limb Group made a significant improvement on the JTHFT and MAS upper arm items. Following four weeks training, the Mobility Group had better locomotor ability than the Upper Limb Group (between-group differences in the 6MWT of 116.4 m, 95% CI 31.4 to 201.3 m, Step Test 2.6 repetitions, 95% CI -1.0 to 6.2 repetitions, and TUGT -7.6 sec, 95% CI -15.5 to 0.2 sec). The JTHFT dexterity scores in the Upper Limb Group were 6.5 sec (95% CI -7.4 to 20.4 sec) faster than the Mobility Group. Our findings support the use of additional task-related practice during inpatient stroke rehabilitation. The circuit class format was a practical and effective means to provide supervised additional practice that led to significant and meaningful functional gains.

A six-week, resource-efficient mobility program after discharge from rehabilitation improves standing in people affected by stroke: Placebo-controlled, randomised trial

Although intervention is effective in reducing the disability associated with stroke, limited resources mean that physiotherapy services often cease by six months after stroke. The purpose of this clinical trial was to investigate the efficacy of resource-efficient physiotherapy services in improving mobility and quality of life after stroke. Twenty-six people with residual walking difficulties after stroke were randomised into an experimental or control group after discharge from physiotherapy services. The experimental group participated in a six-week, home-based mobility program. The control group participated in a six-week, home-based program of upper-limb exercises (i.e. 'sham' mobility exercises). Subjects met with the therapist for prescription of exercises only three times during the six weeks. Strategies used to offset potential problems associated with minimal subject-therapist interaction included videotaped instructions to encourage correct performance of exercises, modification of the environment and involvement of carers to enhance safety, and telephone contact and self-monitoring to promote compliance. Standing (Functional Reach), walking (MAS Item 5) and quality of life (SA-SIP30) were measured prior to, immediately after, and two months after intervention ceased by an assessor who was blinded to group allocation. Subjects in the experimental group demonstrated significant improvement in standing compared to the control group (p = 0.01) which was maintained two months after the cessation of intervention (p = 0.04). There was no difference between the groups in walking (p = 0.50) or quality of life (p = 0.70). The six-week, resource-efficient mobility program was effective in improving some of the mobility in people after discharge from stroke rehabilitation. The provision of resource-efficient programs is recommended wherever possible so that people affected by stroke may continue rehabilitation for longer.

Quality of the stroke rehabilitation research

The Stroke Rehabilitation Evidence-Based Review revealed a wide range of quality scores across primary studies. The aim of this section is to determine what differences there are across studies and to provide a detailed examination of methodological issues in the stroke rehabilitation literature. Methodology of each article was assessed using the Physiotherapy Evidence Database (PEDro) quality scale. Mean PEDro scores and percentage of studies meeting individual PEDro criteria were determined for all studies, for therapy-based studies only, and for drug-based studies only. It was noted that the stroke rehabilitation literature lacked rigor in the area of concealed allocation, blinding of the assessor, and intention-to-treat analysis. Investigation of the methodological quality of stroke rehabilitation literature emphasizes the need for improved treatment protocols, taking into account previous deficits, during research.

Influência de programas não-formais de exercícios (doméstico e comunitário) sobre a aptidão física, pressão arterial e variáveis bioquímicas em pacientes hipertensos

Fundamentos e objetivo: O exercício físico é aceito como estratégia complementar no tratamento da hipertensão arterial. Contudo, são poucos os estudos que analisaram o efeito potencial de programas cujo controle do volume de treinamento é menos estrito, principalmente os não-supervisionados. Assim, o estudo investigou os efeitos de dois programas não-formais de exercício sobre a pressão arterial, aptidão física e perfil bioquímico sanguíneo de adultos hipertensos. Métodos: Foram acompanhados por 18 meses participantes um programa de exercícios não-supervisionado (extramuros) (n = 29; idade = 53 ± 11 anos) e outro de tipo comunitário (ginástica) (n = 42; idade = 62 ± 9 anos). Foram analisados os níveis de pressão arterial, aptidão física (peso corporal, percentual de gordura, IMC, somatório de dobras, relação cintura-quadril, capacidade cardiorrespiratória) e variáveis bioquímicas (colesterol total, LDL, HDL, triglicerídeos e glicemia). O programa extramuros consistia em atividades programadas para serem feitas em casa (caminhada e flexibilidade), três vezes por semana, com treinamento dos sujeitos para controle da intensidade e duração das atividades e preenchimento de fichas individuais, que eram entregues periodicamente à equipe de pesquisa. O programa comunitário envolvia atividades ginásticas em grupo, ministradas por profissionais de educação física, também feitas três vezes por semana. Em ambos os programas, as variáveis foram medidas trimestralmente e os dados tratados por meio de ANOVA para medidas repetidas (p < 0,05). Resultados e conclusão: Os resultados indicaram que ambos os programas tiveram efeitos positivos, principalmente na composição corporal (quantitativa e distribuição regional) e perfil lipídico sanguíneo. As repercussões sobre a pressão arterial, apesar de identificadas estatisticamente, revelaram-se menos consistentes. Não houve efeitos importantes sobre o perfil bioquímico sanguíneo. Conclui-se que programas não-formais de atividades físicas podem ter influências benéficas sobre a condição geral de hipertensos, mas seu potencial quanto a efeitos mais específicos deve ser melhor apreciado em estudos futuros.

Progressive resistance strengthening exercises after stroke: a single-blind randomized controlled trial 1,41No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.4Reprints are not available

OBJECTIVE

To determine the effectiveness of progressive resistance strengthening exercises to improve gross motor function and walking in patients receiving intensive rehabilitation after stroke.

DESIGN

Randomized controlled trial.

SETTING

Five inpatient rehabilitation programs affiliated with teaching hospitals.

PARTICIPANTS

Inclusion criteria included less than 6 months poststroke and recovery of the leg stages 3 to 5 on the Chedoke-McMaster Stroke Assessment (CMSA).

INTERVENTIONS

Both groups received conventional physical therapy programs. In addition, the experimental group performed 9 lower-extremity progressive resistance exercises 3 times a week for the duration of their stay, whereas the control group did the same exercises and for the same duration but without resistance.

MAIN OUTCOME MEASURES

The Disability Inventory of the CMSA and the 2-minute walk test (2MWT) at baseline, 4 weeks, discharge, and 6 months after discharge.

RESULTS

Over the length of stay, the rate of change in the Disability Inventory was.27 points per day in the experimental group and.29 points per day in the control group; the between-group difference was -.02 points per day (95% confidence interval [CI], -.10 to.06; P=.62). At discharge, the rate of change in the 2MWT was -.01 m in the experimental group and.15m in the control group; the between-group difference was -.16 m (95% CI, -.37 to.05; P=.14).

CONCLUSIONS

Progressive resistance strengthening exercises as applied in our study were not effective when compared with the same exercises given without resistance.

A treadmill and overground walking program improves walking in persons residing in the community after stroke: a placebo-controlled, randomized trial 11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To evaluate the effectiveness of a treadmill and overground walking program in reducing the disability and handicap associated with poor walking performance after stroke.

DESIGN

Randomized, placebo-controlled clinical trial with a 3-month follow-up.

SETTING

General community.

PARTICIPANTS

A volunteer sample of 29 ambulatory individuals (less 2 dropouts) who were living in the community after having suffered a stroke more than 6 months previously.

INTERVENTIONS

The experimental group participated in a 30-minute treadmill and overground walking program, 3 times a week for 4 weeks. The control group received a placebo consisting of a low-intensity, home exercise program and regular telephone contact.

MAIN OUTCOME MEASURES

Walking speed (over 10 m), walking capacity (distance over 6 min), and handicap (stroke-adapted 30-item version of the Sickness Impact Profile) measured by a blinded assessor.

RESULTS

The 4-week treadmill and overground walking program significantly increased walking speed (P=.02) and walking capacity (P<.001), but did not decrease handicap (P=.85) compared with the placebo program. These gains were largely maintained 3 months after the cessation of training (P</=.05).

CONCLUSIONS

The treadmill and overground walking program was effective in improving walking in persons residing in the community after stroke. This suggests that the routine provision of accessible, long-term, community-based walking programs would be beneficial in reducing disability after stroke.

Gait and hand function enhancement following training with a multi-segment hybrid-orthosis stimulation system in stroke patients

The majority of stroke survivors continue to suffer residual functional deficits due to weakness and inadequate motor control of their paretic muscles. Non-invasive functional electrical stimulation has been limited to stimulation of only 1-2 muscle groups. The purpose of this study was to test if the use of a multi-segment hybrid orthosis-stimulation system combined with electrically augmented functional training would promote improvement in gait and hand functions of patients with chronic hemiparesis. A control group (n = 9) received individual instructions for specific functional training and self-exercised up to 60 minutes twice daily. The stimulated group (n = 10) received self-administered electrical stimulation training using the NESS system. Training time increased to 60 minutes twice daily and comprised of specific functional exercise. Each group trained for 3 months. Upper limb outcome measures included the Box & Block (B & B) and 3 sub-tests of the Jebsen-Taylor (J & T) battery. Gait outcomes included 10-meter walk time, speed, cadence, and number of steps. Post-test-pretest data were analyzed by unpaired t-tests (P = 0.05). The stimulated group improved significantly compared to the control group in B & B (7.9 +/- 4.5 vs 0.2 +/- 2.2 more blocks); J & T simulated feeding (12.6 +/- 14.8 vs 1.2 +/- 2.09 sec); J & T light object lift (8.2 +/- 9.7 vs. -0.3 +/- 2.8 sec); J & T heavy object lift (7.6 +/- 11.0 vs -0.8 +/- 1.6 sec); walk time (3.3 +/- 1.1 sec vs -0.3 +/- 1.8 sec); walking speed (0.33 +/- 0.12 vs. -0.01 +/- 0.1 m/sec); cadence (0.30 +/- 0.18 vs. -0.02 +/- 0.14 steps/sec). The number of steps over 10 m decreased 2.7 +/- 1.4 vs -0.2 +/- 1.98 steps. We concluded that electrically-dependent functional training with multi-segment hybrid orthosis-stimulation system can improve the studied functional outcomes of chronic stroke survivors.

A community-based group exercise program for persons with chronic stroke

PURPOSE

The purpose of this study was to evaluate the physical and psychosocial effects of an 8-wk community-based functional exercise program in a group of individuals with chronic stroke.

METHODS

Twenty-five subjects (mean age 63 yr) participated in a repeated measures design that evaluated the subjects with two baseline assessments 1 month apart, one postintervention assessment, and one retention assessment 1 month postintervention. Physical outcome measures assessed were the Berg Balance Test, 12-Minute Walk Test distance, gait speed, and stair climbing speed. Psychosocial measures assessed were the Reintegration to Normal Living Index (RNL) and Canadian Occupational Performance Measure (COPM). The 8-wk training consisted of a 60-min, 3 x wk-1 group program that focused on balance, mobility, functional strength, and functional capacity. The program was designed to be accessible by reducing the need for costly one-on-one supervision, specialized settings, and expensive equipment.

RESULTS

Improvements from the exercise program were found for all physical measures and these effects were retained 1-month postintervention. Subjects with lower function improved the most relative to their initial physical status. Significant effects were found for the COPM, but not the RNL Index; however, subjects with lower RNL improved the most relative to their initial RNL Score.

CONCLUSION

A short-term community-based exercise program can improve and retain mobility, functional capacity, and balance and result in a demonstrable impact upon the performance of activities and abilities that were considered meaningful to the subjects. Implementation of such community-based programs has potential for improving activity tolerance and reducing the risk for secondary complications common to stroke (e.g., falls resulting in fractures and cardiac events).

The aftermath of rehabilitation for patients with severe stroke

OBJECTIVE

The study evaluates the aftermath of stroke in patients with very severe disability after their first ever stroke and dismissed after rehabilitation.

MATERIALS AND METHODS

Sixty-nine inpatients were studied, who were highly disabled at discharge with a Functional Independence Measure (FIM) score in the range of 18-39. Their rehabilitation program had lasted 60 days. The degree of functional independence was measured by means of the FIM at the beginning of treatment, at discharge and at follow-up. The data collected were examined by using parametric and distribution-free statistical methods. The role of age in the process of recovery was also evaluated.

RESULTS

All patients were discharged home after 2 months. At 6 month follow-up, 15 patients (21.7%) were lost, 27 (39.1%) had died and 27 (39.1%) lived at home. Among stroke survivors a clear trend toward an improvement was detected during the 6 months observation period. Indeed, the third quartile changed from 33 to 63 and a patient approached to independence (FIM 87). None underwent a rehabilitation program at home beside the relatives' assistance.

CONCLUSIONS

Highly disabled stroke patients are probably to undergo unfavourable outcome but unexpected recovery cannot be ruled-out on the basis of cut-off parameters measured after the acute phase of stroke. Multivariate statistical methods can identify factors which can interfere with functional recovery but are error-prone in setting individual prognosis. Moreover the recovery process may develop in a long period of time. Taking into consideration the spontaneous recovery observed during the follow-up period after the dismissal from rehabilitation ward, a suitable rehabilitation at home might be fruitful in these patients, who should not be considered as "lost".

Obstacle training programme for individuals post stroke: feasibility study

OBJECTIVE

The purposes were threefold: to develop an obstacle ambulation training programme, to recruit and retain individuals post chronic stroke and to assess the effectiveness of the obstacle ambulation training programme.

DESIGN

Intervention study; case series; baseline to post-intervention measures and one month follow-up after intervention.

SETTING

An outpatient department.

SUBJECTS

Five individuals with chronic stroke with mild to moderate functional limitations; convenience sample.

INTERVENTIONS

Therapy consisted of twice weekly sessions for four weeks during which subjects walked along a walkway and over obstacles.

MAIN OUTCOME MEASURES

Motor Assessment Scale--walking section (MAS--time), Six-minute Walk Test distance, walking velocity, and Medical Outcomes Study-36 Health Status Measurement (SF-36).

RESULTS

Significant improvements were seen baseline to post intervention for walking velocity, Six-minute Walk Test, MAS and SF-36 physical function score (p < or = 0.025 for all measures). Most improvements noted at the end of training were retained one month later. The effect sizes ranged from 0.33 to 1.20.

CONCLUSIONS

Substantial improvement in ambulation function and disability level were seen as a result of the obstacle training programme for individuals with chronic stroke. Further investigation is warranted.

A systematic review of exercise trials post stroke

OBJECTIVE

To perform a systematic review of exercise trials post stroke.

DESIGN

A systematic review of controlled clinical trials.

SEARCH STRATEGY

MEDLINE, EMBASE, CINAHL, Amed, Sports Discus, Cochrane controlled trials register and PEDro were searched for relevant trials.

INCLUSION CRITERIA

Studies--randomized or quasi-randomized controlled clinical trials. Participants--Adults of any age with a clinical diagnosis of stroke. Interventions--Any cardiovascular exercise intervention aimed at improving cardiovascular fitness and/or function.

OUTCOMES

Impairment: gait speed, strength, endurance, balance, flexibility, tonus and exercise capacity. Disability: global dependency, functional independence. Extended activities of daily living. Quality of life. Death.

DATA COLLECTION AND ANALYSIS

Two independent reviewers categorized selected trials, documented the methodological quality and extracted the relevant data. Comparisons of cardiovascular exercise interventions versus no cardiovascular intervention were made. Statistical comparisons were carried out using a random effects model to calculate standardized mean differences.

RESULTS

We identified three eligible trials. Small numbers and heterogeneous outcomes limited the analyses and comparisons. Based on the limited data available, we found that cardiovascular exercise post stroke was no better than no exercise with respect to disability, impairment, extended activities of daily living, quality of life and death.

CONCLUSION

Insufficient evidence was identified to establish if cardiovascular exercise has a positive effect on disability, impairment, extended activities of daily living, quality of life and case fatality post stroke.

Therapy-based rehabilitation services for stroke patients at home

BACKGROUND

Stroke Unit care is now accepted as an effective service model for hospital care, but the effectiveness of outpatient care is less certain. This review focuses on therapy-based rehabilitation services targeted at stroke patients living at home.

OBJECTIVES

To assess the effects of therapy-based rehabilitation services targeted towards stroke patient resident in the community within one year of stroke onset/ discharge from hospital following stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched November 2001). In addition we searched the following electronic databases: the Cochrane Controlled Trials Register (Cochrane Library Issue 4, 2001), MEDLINE (1996 - Nov 2001), EMBASE (1980 - Nov 2001), CINAHL (1983 - Nov 2001), PsycINFO (1967 - Nov 2001), AMED (1985 - Nov 2001), Wilson Social Sciences Abstracts (1984-Nov 2001), Science Citation Index and Social Sciences Citation Index (1981-Nov 2001). Other strategies to ensure identification of all potentially relevant trials included scanning reference lists of relevant articles and original papers, personal communication and hand searching journals.

SELECTION CRITERIA

All unconfounded, truly randomised controlled trials of stroke patients resident in the community receiving a therapy service intervention, which was compared to conventional or no care. Therapy services were those provided by physiotherapy, occupational therapy, or multidisciplinary staff working with patients primarily to improve task-orientated behaviour (e.g. walking, dressing) and hence increase activity and participation.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials and extracted data on a number of prespecified outcomes. The primary outcomes were the proportion of patients who had deteriorated or were dependent in personal activities of daily living and performance in personal activities of daily living at the end of follow-up.

MAIN RESULTS

We identified a heterogeneous group of 14 trials including 1617 patients. Therapy-based rehabilitation services reduced the odds of a poor outcome (Peto odds ratio 0.72 (95% CI 0.57 to 0.92; P = 0.009) and increased personal activity of daily living scores (standardised mean difference 0.14 (95% CI 0.02 to 0.25; P = 0.02). For every 100 stroke patients resident in the community receiving therapy-based rehabilitation services, 7 (95% CI 2 to 11) patients would be spared a poor outcome, assuming 37.5% would have had a poor outcome with no treatment.

REVIEWER'S CONCLUSIONS

Therapy-based rehabilitation services targeted towards stroke patients living at home appear to improve independence in personal activities of daily living. However, the evidence is derived from a review of heterogeneous interventions and therefore further exploration of the interventions is justifiable.

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

BACKGROUND

There are a number of different approaches to physiotherapy treatment following stroke. Central to these are approaches based on 'neurophysiological' principles, 'motor learning' principles and 'orthopaedic' principles.

OBJECTIVES

To determine if there is a difference in the recovery of postural control and lower limb function in patients with stroke if physiotherapy treatment is based on orthopaedic or neurophysiological or motor learning principles, or on a mixture of these treatment principles.

SEARCH STRATEGY

This review drew on the search strategy developed by the Stroke Group as a whole. Relevant trials were identified in the Stroke Group Trials Register of Controlled Trials which was last searched in May 2001. We also searched the Cochrane Controlled Trials Register (Cochrane Library, Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999) and CINAHL (1982-1999) and contacted experts and researchers with an interest in stroke.

SELECTION CRITERIA

Studies - randomised or quasi-randomised controlled trials. Participants - adults with a clinical diagnosis of stroke. Interventions - physiotherapy treatment approaches aimed at promoting the recovery of postural control and lower limb function. Outcomes - measures of disability, motor impairment or participation.

DATA COLLECTION AND ANALYSIS

Two independent reviewers categorised the identified trials according to the inclusion/exclusion criteria, documented the methodological quality and extracted the data.

MAIN RESULTS

Eleven trials were included in the review, three of which were included in two comparisons. Four trials compared a neurophysiological approach with another approach; four trials compared a motor learning approach with another approach; four studies compared a mixed approach with another approach; two trials reported comparisons of sub-groups of the same approach. A large number of heterogeneous outcome measures were used, limiting the comparison of trial results. No one type of approach had a significantly better outcome than any other type of approach.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to conclude that any one physiotherapy treatment approach is more effective than another in promoting the recovery of postural control or lower limb function.

Effect of force-feedback treatments in patients with chronic motor deficits after a stroke

OBJECTIVE

To assess the effects a motor reeducation approach based on static dynamometers used to provide feedback on the force produced.

DESIGN

The study design was a single-blind, randomized, controlled trial. Chronic stroke subjects participated in a 6-wk, thrice-weekly, force-feedback program of either the upper paretic limb (n = 13) or the lower paretic limb (n = 12). Baseline and postintervention assessments of the performance of both the upper and the lower limb were measured for each subject, the untreated paretic limb of each group serving as a control for the other group.

RESULTS

With the exception of the handgrip force, strength measurements of the treated limb increased after completion of the treatment. The outcome measurements of the upper limb of the subjects included in the upper paretic limb were not significantly different after treatment from those measured in the lower paretic limb. In contrast, gait velocity and the distance walked in 2 min increased after treatment in the lower paretic limb as compared with the upper paretic limb, whereas the scores in the Fugl-Meyer test for the lower limb and the timed up-and-go test did not increase for either group after treatment.

CONCLUSION

The results indicate that treatment of the lower limb based on force feedback produces an improvement of gait velocity.

Performance-based gait tests for acute stroke patients

OBJECTIVE

Qualitative measures may not differentiate severity of deficits after an acute or subacute stroke. The aim of this study was to contrast the utility of performance-based gait tests with qualitative measures in a sample of acute stroke patients.

DESIGN

Twenty acute stroke subjects had their performance-based gait measured by gait speed, walking distance, gait energy expenditure, and gait energy cost. They were also qualitatively evaluated for cognition, functional outcomes, motor impairment, and Functional Ambulation Category.

RESULTS

Strong and significant correlations were observed among performance-based gait tests. Qualitative scales indicated moderate to minimal deficits in each domain evaluated, although they were not correlated among themselves, except for Functional Ambulation Category and FIM and FIM and Mini-Mental State Exam. Functional Ambulation Category correlated with performance-based gait tests.

CONCLUSIONS

Performance-based gait tests are feasible to conduct during early recovery after a stroke and allow better discrimination among the patients than qualitative measures.

Follow-up services for stroke survivors after hospital discharge--a randomized control study

OBJECTIVE

To evaluate whether follow-up services for stroke survivors could improve functional outcome and reduce readmission rate. In this paper results of functional outcome are reported.

DESIGN

Randomized controlled trial allocating patients to one of three different types of aftercare: (1) follow-up home visits by a physician, (2) physiotherapist instruction in the patient's home, or (3) standard aftercare.

SUBJECTS

Stroke patients with persisting impairment and disability who, after completing inpatient rehabilitation, were discharged to their homes.

OUTCOME MEASURES

Six months after discharge, functional outcome was assessed with Functional Quality of Movement, Barthel Index, Frenchay Activity Index and Index of Extended Activites of Daily Living.

RESULTS

One-hundred and fifty-five stroke patients were included in the study. Fifty-four received follow-up home visits by a physician, 53 were given instructions by a physiotherapist in their home and 48 received standard aftercare only. No statistically significant differences in functional outcome six months after discharge were demonstrated between the three groups. However, all measurements showed a tendency towards higher scores indicating better function in both interventions groups compared with the control group.

CONCLUSION

Follow-up services after stroke may be a way of improving functional outcome. The results of the present study should be evaluated in future trials. More research in this field is needed, especially studies of how to support stroke survivors to resume social and leisure activities.

Functional and locomotive characteristics of stroke survivors in Japanese community-based rehabilitation

OBJECTIVE

The purposes of this study were as follows: (1) to compare the characteristics of functional fitness of Japanese stroke survivors with those of control subjects of a similar age; and (2) to relate these characteristics to the extent of physical impairment and the period after stroke onset to better design community-based rehabilitation programs for stroke survivors.

DESIGN

One hundred fifty-three stroke survivors who participated in community-based rehabilitation and 119 control subjects were measured. Twelve performance test items were designed to assess functional fitness.

RESULTS

The average functional fitness score for the stroke survivors was significantly lower than that of the control group. However, some survivors had higher performance scores than the control group. Significant correlations were shown between some functional fitness items and Brunnstrom recovery stage in the stroke survivors.

CONCLUSION

The large variability in functional fitness scores for stroke survivors indicates a need to design variable rehabilitation programs so that survivors can be grouped according to their specific levels of functional fitness.

Reduction of spastic hypertonia during repeated passive knee movements in stroke patients

OBJECTIVES

To quantify changes in spastic hypertonia during repeated passive isokinetic knee movements in stroke patients and to assess the role of muscle activity.

DESIGN

A between-groups design with repeated measures.

SETTING

Rehabilitation center for stroke patients.

PARTICIPANTS

Ten stroke patients with hypertonia and 10 healthy subjects matched for age and gender.

INTERVENTION

With an isokinetic apparatus, movements were imposed on the knee in series of 10 repetitions at speeds of 60 degrees /s, 180 degrees /s, and 300 degrees /s.

MAIN OUTCOME MEASURES

Spastic hypertonia was assessed on the basis of torque measurement and electromyographic activity of the quadriceps, hamstrings, and gastrocnemius muscles.

RESULTS

Compared with the controls, stroke patients presented a significantly stronger torque reduction during the mid- and endphases of movements at all speeds tested (P<.05). The strongest torque decline occurred during knee flexion and during the first movements. The effect increased toward the end phase of movements and with increasing speeds. The effect of movement repetitions on torque measurements was unchanged after electromyographic activity was included in the statistical analysis, except during extension movements at 180 degrees /s and 300 degrees /s.

CONCLUSION

Passive movements of the knee induced a decrease of spastic hypertonia in stroke patients through a combination of reflexive and mechanical factors. The role of these mechanisms is velocity dependent and differs for flexion and extension movements.

Reliability of gait speed measured by a timed walking test in patients one year after stroke

OBJECTIVE

To assess the reliability of gait speed in late-stage stroke patients.

DESIGN

Test-retest reliability of three timed walks to 10 metres repeated during two assessments one week apart.

SETTING

The patient's home.

SUBJECTS

Twenty-two stroke patients with mobility problems more than one year after stroke.

MAIN OUTCOME MEASURE

Gait speed measured in seconds taken to walk 10 metres.

STATISTICAL ANALYSIS

Intraclass correlations (ICCs) with 95% confidence interval (CI) and the Bland and Altman method for assessing agreement by calculating the mean difference between measurements (d); the 95% CI for d; the standard deviation of the difference (SDdiff); a reliability coefficient and the 95% limits of agreement.

RESULTS

There was a trend for decreased times taken to walk 10 metres both within each assessment and between assessments. ICCs for within-assessment reliability were 0.95-0.99. The d (SDdiff) for the second and third walks for assessment 1 was -1.00 (2.63) seconds and for assessment 2 was -0.70 (1.58) seconds. The reliability coefficient was 5.26 for assessment 1 and 3.17 for assessment 2. ICCs for between-assessment reliability were 0.87-0.88. The d (SDdiff) for the comparison of the third walks at assessment 1 and assessment 2 was -0.90 (5.01) seconds. The reliability coefficient was 10.02 and the 95% limits of agreement were -10.92 to +9.12 seconds.

CONCLUSION

Within-assessment gait speed measured at home is highly reliable. The between-assessment reliability of gait speed measurement is less reliable but comparable with other studies.

Age- and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds

BACKGROUND AND PURPOSE

The interpretation of patient scores on clinical tests of physical mobility is limited by a lack of data describing the range of performance among people without disabilities. The purpose of this study was to provide data for 4 common clinical tests in a sample of community-dwelling older adults.

SUBJECTS

Ninety-six community-dwelling elderly people (61-89 years of age) with independent functioning performed 4 clinical tests.

METHODS

Data were collected on the Six-Minute Walk Test (6MW), Berg Balance Scale (BBS), and Timed Up & Go Test (TUG) and during comfortable- and fast-speed walking (CGS and FGS). Intraclass correlation coefficients (ICCs) were used to determine the test-retest reliability for the 6MW, TUG, CGS, and FGS measurements. Data were analyzed by gender and age (60-69, 70-79, and 80-89 years) cohorts, similar to previous studies. Means, standard deviations, and 95% confidence intervals for each measurement were calculated for each cohort.

RESULTS

The 6MW, TUG, CGS, and FGS measurements showed high test-retest reliability (ICC [2,1]=.95-.97). Mean test scores showed a trend of age-related declines for the 6MW, BBS, TUG, CGS, and FGS for both male and female subjects.

DISCUSSION AND CONCLUSION

Preliminary descriptive data suggest that physical therapists should use age-related data when interpreting patient data obtained for the 6MW, BBS, TUG, CGS and FGS. Further data on these clinical tests with larger sample sizes are needed to serve as a reference for patient comparisons.

Detecting change in patients with stroke using the Berg Balance Scale

The Berg Balance Scale (BBS) was designed to help determine change in functional standing balance over time. The purpose of this paper was to estimate the minimum detectable change score (MDC) using the standard error of measure (SEM), thereby providing a means to decide if genuine change had occurred. Calculation of the agreement regarding the presence of change as determined by the MDC and clinicians' perceptions was performed to give an indication of the validity of this criterion value. Forty-eight subjects who were receiving inpatient rehabilitation after stroke were assessed on consecutive days by two raters using the BBS. The MDC analysis suggests that a change of +/- 6 BBS points is necessary to be 90% confident of genuine change. Only 25/45 subjects showed agreement between the statistically derived presence of change and clinicians' perceptions of change. The lack of agreement may relate to the validity of the SEM/MDC methodology to determine the criterion BBS value, the heterogeneity of the subjects, or the use of clinician gestalt impressions of change.

Progressive versus catastrophic loss of the ability to walk: implications for the prevention of mobility loss

OBJECTIVES

Loss of mobility is an important functional outcome that can have devastating effects on quality of life and the ability of older persons to remain independent in the community. Although a large amount of research has been done on risk factors for disability onset, little work has focused on the pace of disability progression. This study characterizes the development of severe walking disability over time and evaluates risk factors and subsequent mortality as they relate to mobility disability with progressive or catastrophic onset.

DESIGN

Population-based prospective cohort study with annual follow-up assessments for up to 7 years

SETTING

Three communities of the Established Populations for Epidemiologic Studies of the Elderly.

PARTICIPANTS

There were 5,355 persons not disabled at baseline and the first follow-up who had adequate data available to classify mobility disability during subsequent follow-ups.

MEASUREMENTS

Severe mobility disability was defined as the need for help from a person to walk across a room or inability to walk across a room. Those developing severe mobility disability were classified as having progressive mobility disability if they had been unable to walk half a mile in either of the prior 2 years. They were classified as having catastrophic mobility disability if they reported having been able to walk half a mile in two previous annual interviews.

RESULTS

The overall incidence of severe mobility disability was 11.6 cases/1,000 person years. Those age 85 and older or having three or more chronic conditions at baseline were significantly more likely to develop progressive disability than catastrophic disability. Stroke, hip fracture, and cancer occurring during follow-up were associated with very high risk of severe mobility disability. For stroke and hip fracture, the risk was twice as high for catastrophic disability as for progressive disability, but this difference did not reach statistical significance. Risk for catastrophic disability from cancer was significantly greater than for progressive disability. Half of catastrophic disability subjects had stroke, hip fracture, or cancer in the year immediately preceding this disability. Incident heart attack did not predict severe mobility disability. Among those who developed severe mobility disability, type of disability did not influence subsequent survival for the first 3 years, but beyond 3 years those with catastrophic disability had a relative risk of death of 0.4 (95% confidence interval 0.2-0.9) compared with those with progressive disability.

CONCLUSION

The observation that risk factors and mortality outcomes were both different for progressive and catastrophic mobility disability supports the value of ascertaining the pace of disability development as a useful characterization of disability. Further progress in developing prevention and treatment strategies may be made by taking the pace of disability development into account.

Effects of isokinetic strength training on walking in persons with stroke: a double-blind controlled pilot study

OBJECTIVES

The goal most often stated by persons with stroke is improved walking function. The purpose of this study was to determine the effects of isokinetic strength training on walking performance, muscle strength, and health-related quality of life in survivors of chronic stroke.

METHODS

Twenty participants (age, 61.2 +/- 8.4 years) with chronic stroke were randomized into 2 groups. The experimental group undertook maximal concentric isokinetic strength training, whereas the control group received passive range of motion of the paretic lower extremity 3 times a week for 6 weeks. The Kin-Com Isokinetic Dynamometer (Chattanooga Group Inc., TN) was used for both the strengthening and passive range of motion exercises. The Mann-Whitney U test was used to compare the changes in scores (postintervention minus baseline) between the control and experimental groups for a composite lower extremity strength score, walking speed (level-walking and stair-walking) and health-related quality of life measure (36-Item Short Form Health Survey [SF-36]).

RESULTS

Both the experimental and control groups increased their strength and walking speed postintervention; however, there were no differences in the changes in walking speed between the groups. There was a trend (P = .06) toward greater strength improvement in the experimental group compared with the control group. No changes in SF-36 scores were found in either group.

CONCLUSIONS

Intervention aimed at increasing strength did not result in improvements in walking. The results of this study stress the importance of controlled clinical trials in determining the effect of specific treatment approaches. Strength training in conjunction with other task-related training may be indicated.

Can brain-injured patients participate in an aerobic exercise programme during early inpatient rehabilitation?

OBJECTIVE

We investigated the capacity of brain-injured patients to participate in an aerobic exercise programme early after injury.

DESIGN

Retrospective analysis of exercise achievements in patients participating in a randomized controlled trial.

SETTING AND SUBJECTS

Ninety patients participated in an exercise training programme on a cycle ergometer at four inpatient neurological rehabilitation units for younger patients. At intake, impairments and function were rated on: Motricity Index, Ashworth Scale, Berg Balance Scale, Barthel Index and Functional Independence Measure.

INTERVENTIONS

Patients cycled for up to 30 minutes three times weekly for 24-36 sessions over 12 weeks.

MAIN OUTCOME MEASURES

Exercise performance was measured by: (a) number of sessions to achieve a cycling time of 30 minutes, (b) overall mean cycling time per session over 24 sessions and (c) mean time per session cycling at >60% of age predicted maximum heart rate (HR max) over 24 sessions.

RESULTS

Fifty-five patients completed 24 sessions. Thirty-five withdrew, largely for logistic reasons, before completing training; they were significantly less disabled than the 55 who remained. Forty-four of the 55 patients trained for an average of at least 20 minutes per session, 18 training at >60% HR max for this time. There were no differences in performance on the three exercise parameters between two groups of patients with baseline Barthel scores of < or = 12 and > or = 13.

CONCLUSIONS

Brain-injured patients with a range of disabilities have the capacity to participate in an exercise programme during early inpatient rehabilitation, though some may take longer to achieve adequate intensity of aerobic exercise.

Walking speed over 10 metres overestimates locomotor capacity after stroke

OBJECTIVE

To examine 10-m comfortable walking speed and 6-minute distance in healthy individuals and individuals after stroke and to assess the level of disability associated with poor walking endurance after stroke.

DESIGN

Descriptive study in which comfortable walking speed over 10 m and distance covered in 6 minutes (6-minute walk test) were compared between healthy subjects and subjects after stroke.

SUBJECTS

Twelve healthy subjects and 14 subjects after stroke.

MAIN OUTCOME MEASURES

Walking speed and 6-minute distances were compared between groups. In addition, for each group, actual distance walked in 6 minutes was compared with the distance predicted by the 10-m walking speed test and the distance predicted by normative reference equations.

RESULTS

Subjects after stroke had significant reductions in 10-m speed and 6-minute distance compared with healthy subjects (p < 0.05). Subjects after stroke were not able to maintain their comfortable walking speed for 6 minutes, whereas healthy subjects walked in excess of their comfortable speed for 6 minutes. The average distance walked in 6 minutes by individuals after stroke was only 49.8+/-23.9% of the distance predicted for healthy individuals with similar physical characteristics.

CONCLUSION

In our subjects after stroke, walking speed over a short distance overestimated the distance walked in 6 minutes. Both walking speed and endurance need to be measured and trained during rehabilitation.

Treadmill training improves fitness reserve in chronic stroke patients

OBJECTIVE

To investigate the hypothesis that treadmill training will improve peak fitness, while lowering the energy cost of hemiparetic gait in chronic stroke patients.

DESIGN

Noncontrolled exercise intervention study with repeated-measures analysis.

SETTING

Hospital-based senior exercise research center.

PARTICIPANTS

Twenty-three patients (mean age +/- standard deviation [SD] 67 +/- 8 yr) with chronic hemiparetic gait after remote (>6 mo) ischemic stroke.

INTERVENTION

Three 40-minute sessions of treadmill exercise weekly for 6 months.

MAIN OUTCOME MEASURES

Peak exercise capacity (VO2peak) and rate of oxygen consumption during submaximal effort treadmill walking (economy of gait) by open circuit spirometry and ambulatory workload capacity before and after 3 and 6 months of training.

RESULTS

Patients who completed 3 months of training (n = 21) increased their VO2peak +/- SD from 15.4 +/- 2.9 mL x kg(-1) x min(-1) to 17.0 +/- 4.4 mL x kg(-1) x min(-1) (p <.02) and lowered their oxygen demands of submaximal effort ambulation from 9.3 +/- 2 mL x kg(-1) x min(-1) to 7.9 +/- 1.5 mL x kg(-1) x min(-1) (p =.002), which enabled them to perform the same constant-load treadmill task using 20% less of their peak exercise capacity (62.3% +/- 17.2% vs 49.9% +/- 19.3%, p <.002). Gains in VO2peak and economy of gait plateaued by 3 months, while peak ambulatory workload capacity progressively increased by 39% (p <.001) over 6 months.

CONCLUSIONS

Treadmill training improves physiologic fitness reserve in chronic stroke patients by increasing VO2peak while lowering the energy cost of hemiparetic gait, and increases peak ambulatory workload capacity. These improvements may enhance functional mobility in chronic stroke patients.

Exercise therapy for arm function in stroke patients: a systematic review of randomized controlled trials

OBJECTIVE

Assessment of the available evidence for the effectiveness of exercise therapy to improve arm function in patients who have suffered from a stroke.

METHODS

A systematic search of bibliographical databases and reference checking were performed to identify publications on randomized controlled trials (RCTs) which evaluated the effect of exercise therapy on arm function in stroke patients. The methodological quality was assessed systematically by two raters, based on a standardized list of methodological criteria. Study characteristics, such as the chronicity and severity of impairment of the patient population, the amount and duration of interventions, and specific methodological criteria, were related to reported effects.

RESULTS

Thirteen RCTs were identified, six of which reported positive results on an arm function test. In five of these six studies there was a contrast in amount or duration of exercise therapy between groups. Methodological scores ranged from 5 to 15 (maximum possible score: 19 points).

CONCLUSION

Insufficient evidence made it impossible to draw definitive conclusions about the effectiveness of exercise therapy on arm function in stroke patients. The difference in results between studies with and without contrast in the amount or duration of exercise therapy between groups suggests that more exercise therapy may be beneficial.

The effect of aerobic training on rehabilitation outcomes after recent severe brain injury: a randomized controlled evaluation

OBJECTIVE

To examine the impact of fitness training with recently brain-injured inpatients on exercise capacity and functional and psychologic outcome measures.

DESIGN

A randomized controlled trial of exercise versus relaxation training for 3 months. Blind assessments were conducted before and after the end of a 12-week training program, as well as at follow-up assessment 12 weeks posttraining.

SETTING

Four regional neurologic inpatient rehabilitation units.

PATIENTS

Of 157 patients recruited 24 +/- 14 weeks after single-incident brain injury, 142 patients were assessed at week 12, and 128 patients at follow-up.

INTERVENTIONS

Patients were randomized between cycle ergometer aerobic training and a relaxation training control condition, which was theoretically inert with respect to cardiovascular fitness.

MAIN OUTCOME MEASURES

Validation of exercise training (peak work rate, peak heart rate, body mass index); mobility and physical function (modified Ashworth scale, Berg balance scale, Rivermead Mobility Index, 10-m walk velocity); disability and dependency (Barthel index, FIMtrade mark instrument, Nottingham Extended Activities of Daily Living); and psychologic function (fatigue questionnaire, Hospital Anxiety and Depression Scale).

RESULTS

Significant improvements in exercise capacity (p <.05) in the exercise training group (n = 70) relative to the control group (n = 72) were not matched by greater improvements in functional independence, mobility, or psychologic function, at either 12 weeks or follow-up.

CONCLUSIONS

The benefits of improved cardiovascular fitness did not appear to extend to measurable change in function or psychologic state.

Reliability of lower extremity isokinetic strength testing in adults with stroke

OBJECTIVE

To evaluate the reliability of isokinetic strength testing of knee flexion and extension at 60 degrees per second, and ankle plantar flexion and dorsiflexion at 30 degrees per second in adults with stroke.

DESIGN

Test-retest using intraclass correlation coefficients (ICC).

SETTING

Human performance laboratory.

SUBJECTS

Ten adults post stroke with a mean age of 64 years (five males) and 10 adults without neurological injury with a mean age of 69 years (three males) who served as controls.

MAIN OUTCOME MEASURES

Peak torque and average torque.

RESULTS

The reliability of strength of the less-affected lower extremity was high with values ranging from 0.75 to 0.97. Knee extension, ankle plantar flexion and the peak torque of dorsiflexion were reliable for the affected limb, ranging from 0.80 to 0.90. In contrast, affected knee flexion was not reliable with values of 0.48 and 0.44 for peak torque and average peak torque respectively.

CONCLUSIONS

Isokinetic knee and ankle strength of the less-affected limb are reliable. Isokinetic strength of the affected lower extremity is also reliable with the noted exception of knee flexion.

Cerebral blood volume and oxygenation among poststroke hemiplegic patients: effects of 13 rehabilitation tasks measured by near-infrared spectroscopy

OBJECTIVE

To measure with near-infrared spectroscopy (NIRS) the changes in cerebral hemodynamics and oxygenation in the prefrontal cortex of poststroke patients with hemiplegia performing several rehabilitation tasks and to analyze the different effects of the tasks.

DESIGN

Case series pilot study.

SETTING

Hospitals and facilities near Tsukuba, Japan.

PARTICIPANTS

Twenty-four healthy volunteers and 44 patients with hemiplegia.

INTERVENTIONS

For healthy volunteers, conventional rehabilitation tasks of head-up tilt (HUT), calculation, and ergometer. For patients with hemiplegia, these 3 tasks plus reading aloud, listening to music, reciprocal extension, nonparalyzed extension, passive range of motion, pulley, bridge, facilitation, stand-up, and gait.

MAIN OUTCOME MEASURES

Changes in cerebral blood volume (CBV) and cerebral oxygen volume (COV) in the prefrontal region sensed by a noninvasive NIRS device placed midforehead in healthy volunteers or on the impaired side in patients with hemiplegia. Computer analysis of the quality and quantity of the CBV and COV change patterns.

RESULTS

In healthy subjects, the change patterns of the 3 tasks were clearly different: decrease in COV with HUT, limited increase in CBV and COV with calculation tasks, and gradual increase in CBV and COV with ergometer tasks. In patients with hemiplegia, significant (positive) CBV changes were observed in ergometer, facilitation, stand-up, and gait and significant (negative) changes with Romover. Significant (positive) COV changes were observed in ergometer and facilitation and (negative) in HUT.

CONCLUSIONS

NIRS is useful for monitoring the change in regional hemodynamics and oxygenation in rehabilitation; some tasks commonly used in rehabilitation, such as ergometer and facilitation, increase both CBV and COV in the affected prefrontal cortex of patients with hemiplegia.

High intensity strength training improves strength and functional performance after stroke

OBJECTIVE

To evaluate the effects of a progressive resistance strength training program on changes in muscle strength, gait, and balance in older individuals 1 yr after stroke, seven individuals were recruited who were greater than 60-yr-old, 1 yr after stroke, living at home, and able to follow verbal commands.

DESIGN

Subjects participated in a 12-wk 2x per wk resistance training program at 70% of 1 repetition maximum.

RESULTS

Lower limb strength improved 68% on the affected side and 48% on the intact side during training, with the largest increases observed for hip extension (affected side: 88%, P < 0.01; intact side: 103%, P < 0.001). Repeated chair stand time decreased 21% (P < 0.02). Motor performance assessed by the Motor Assessment Scale improved 9% (P < 0.04) and static and dynamic balance (Berg balance scale) improved 12% (P < 0.004). Progressive resistance training in individuals 1 yr after stroke improves affected and intact side lower limb strength and was associated with gains in chair stand time, balance, and motor performance.

CONCLUSIONS

These results support the concept that strength training is an appropriate intervention to improve the quality of physical function in older community dwelling stroke survivors.

Stair negotiation in older people: a review

Locomotion on stairs is among the most challenging and hazardous activities of daily living for older individuals. This is evidenced by the reports that stair falls account for more than 10% of fatal fall accidents. The demands that stairs place on the musculoskeletal and cardiovascular systems are compounded by the need for input from the somatosensory, visual, and vestibular systems at various stages in the task. Many of these collaborating systems deteriorate with aging, thus increasing the difficulty and risk of failure in a task that inherently involves exposure to significant danger. The task itself varies in its degree of challenge depending on many structural and environmental factors that are outside the control of the stair user. This review explores existing literature in the area of stair negotiation by older persons in an effort to define the key factors associated with difficulty and safety on stairs and to interpret these findings in the light of possible interventions that could increase stair safety. Further research is needed to ensure that current recommendations for stair design are suitable for older stair users. A Glossary of Terms is also provided.