Strength Training for Skeletal Muscle Endurance after Stroke

Effects of muscle strength exercise on muscle mass and muscle strength in patients with stroke: a systematic review and meta-analysis

This study systematically reviews the effects of muscle strength exercises on muscle mass and strength in stroke patients by analyzing randomized controlled trials. Ten studies, involving a total of 378 stroke patients, were included in the meta-analysis. The standardized mean difference (SMD) and confidence intervals (CIs) were calculated using a random effects model. The results indicated that strength exercises had a medium effect on increasing muscle strength in stroke patients (SMD, 0.6; 95% CI, 0.47-0.72; I 2 =51%; P<0.05). Specifically, strength exercises were found to be particularly effective in chronic stroke patients, showing a medium effect on muscle strength (SMD, 0.68; 95% CI, 0.55-0.81; I 2 =45%; P<0.05). The study also compared the effects based on repetition maximum (RM) settings, revealing that strength increased significantly regardless of whether RM was used, with studies showing medium effects (with RM: SMD, 0.52; 95% CI, 0.4-0.64; I 2 =0%; P<0.05; without RM: SMD, 0.65; 95% CI, 0.4-0.91; I 2 =72%; P<0.05). The study concludes that strength exercises are beneficial for improving muscle strength in chronic stroke patients, but the use of RM to set exercise intensity is not strictly necessary.

Maximal Number of Repetitions at Percentages of the One Repetition Maximum: A Meta-Regression and Moderator Analysis of Sex, Age, Training Status, and Exercise

The maximal number of repetitions that can be completed at various percentages of the one repetition maximum (1RM) [REPS ~ %1RM relationship] is foundational knowledge in resistance exercise programming. The current REPS ~ %1RM relationship is based on few studies and has not incorporated uncertainty into estimations or accounted for between-individuals variation. Therefore, we conducted a meta-regression to estimate the mean and between-individuals standard deviation of the number of repetitions that can be completed at various percentages of 1RM. We also explored if the REPS ~ %1RM relationship is moderated by sex, age, training status, and/or exercise. A total of 952 repetitions-to-failure tests, completed by 7289 individuals in 452 groups from 269 studies, were identified. Study groups were predominantly male (66%), healthy (97%), < 59 years of age (92%), and resistance trained (60%). The bench press (42%) and leg press (14%) were the most commonly studied exercises. The REPS ~ %1RM relationship for mean repetitions and standard deviation of repetitions were best described using natural cubic splines and a linear model, respectively, with mean and standard deviation for repetitions decreasing with increasing %1RM. More repetitions were evident in the leg press than bench press across the loading spectrum, thus separate REPS ~ %1RM tables were developed for these two exercises. Analysis of moderators suggested little influences of sex, age, or training status on the REPS ~ %1RM relationship, thus the general main model REPS ~ %1RM table can be applied to all individuals and to all exercises other than the bench press and leg press. More data are needed to develop REPS ~ %1RM tables for other exercises.

Comparative efficacy of different exercise methods to improve cardiopulmonary function in stroke patients: a network meta-analysis of randomized controlled trials

Background

Although some studies have shown that exercise has a good effect on improving the cardiopulmonary function of stroke patients, it still needs to be determined which exercise method does this more effectively. We, therefore, aimed to evaluate the effectiveness of different exercise methods in improving cardiovascular function in stroke patients through a network meta-analysis (NMA), providing a basis to select the best treatment plan for stroke patients.

Methods

We systematically searched CNKI, WanFang, VIP, CBM, PubMed, Embase, Web of Science, and The Cochrane Library databases from establishment to 30 April 2023. Randomized controlled trials (RCTS) on exercise improving cardiopulmonary function in stroke patients were included, and we screened the included articles and extracted the relevant data. RevMan (version 5.4) and Stata (version 17.0) were used for data analysis.

Results

We included 35 RCTs and a total of 2,008 subjects. Intervention measures included high-intensity interval training (HIIT), aerobic training (AT), resistance training (RT), combined aerobic and resistance exercise (CE), and conventional therapy (CT). In the network meta-analysis, the surface under the cumulative ranking area (SUCRA) ranking result indicated that HIIT improved peak oxygen uptake (VO2peak) and 6 mins walking distance (6MWD) optimally, with rankings of HIIT (100.0%) > CE (70.5%) > AT (50.2%) > RT (27.7%) > CT (1.6%), and HIIT (90.9%) > RT (60.6%) > AT (48.9%) > RT (48.1%) > CT (1.5%), respectively. The SUCRA ranking result showed that CE improved systolic blood pressure (SBP) and diastolic blood pressure (DBP) optimally, with rankings of CE (82.1%) > HIIT (49.8%) > AT (35.3%) > CT (32.8%), and CE (86.7%) > AT (45.0%) > HIIT (39.5%) > CT (28.8%), respectively.

Conclusion

We showed that exercise can effectively improve the cardiopulmonary function of stroke patients. HIIT was the most effective in improving VO2peak and 6MWD in stroke patients. CE was the most effective in improving SBP and DBP in stroke patients. However, due to the limitations of existing clinical studies and evidence, larger sample size, multi-center, and high-quality RCTs are needed to verify the above conclusions in the future.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier [CRD42023436773].

Multi-Modal versus Uni-Modal Treatment for the Recovery of Lower Limb Motor Function in Patients after Stroke: A Systematic Review with Meta-Analysis

The aim of this study is to evaluate whether the multimodal treatment based on both resistance and endurance training for the recovery of lower limb function in post-stroke patients is more effective than unimodal treatment. Six electronic databases were searched. The included articles were firstly analysed for methodological quality and then quantitatively analysed for the following outcomes: endurance, knee-extensor muscle strength, gait speed, and aerobic capacity. The treatment effect was analysed with the mean difference (MD) or standardised mean difference (SMD). From a total of 4439 records, 10 studies met the inclusion criteria for the qualitative analysis, whereas 7 studies were included in the quantitative analysis. There is a significant difference favourable to the group with multimodal treatment for knee-extensor muscle strength (SMD = 1.25; 95% CI 0.97, 1.53, I2 = 42%), both for the affected and the unaffected side. Multimodal treatments are a valid choice in the field of post-stroke rehabilitation. In particular, the combination of resistance and endurance training is useful to maximise the recovery of knee-extensor muscle strength, which in turn could be beneficial for achieving upright position and walking, allowing patients to improve independence levels in their activities of daily life.

Effect of lower limb resistance training on ICF components in chronic stroke: A systematic review and meta-analysis of RCTs

BACKGROUND

Resistance training (RT) effectively promotes functional independence after stroke.

OBJECTIVES

To investigate the effect of lower limb RT on body structure and function (muscle strength, postural balance), activity (mobility, gait) and participation (quality of life, impact of stroke on self-perceived health) outcomes in individuals with chronic stroke.

METHODS

Six databases were searched from inception until September 2022 for randomized controlled trials comparing lower limb RT to a control intervention. The random-effects model was used in the meta-analyses. Effect sizes were reported as standardized mean differences (SMD). Quality of evidence was assessed using the GRADE approach.

RESULTS

Fourteen studies were included. Significant improvements were found in body structure and function after lower limb RT: knee extensors (paretic side - SMD: 1.27; very low evidence), knee flexors (paretic side - SMD: 0.51; very low evidence; non-paretic side - SMD: 0.52; low evidence), leg press (paretic side - SMD: 0.83; very low evidence) and global lower limb muscle strength (SMD: -1.47; low evidence). No improvement was found for knee extensors (p = 0.05) or leg press (p = 0.58) on the non-paretic side. No improvements were found in the activity domain after lower limb RT: mobility (p = 0.16) and gait (walking speed-usual: p = 0.17; walking speed-fast: p = 0.74). No improvements were found in the participation domain after lower limb RT: quality of life (p > 0.05), except the bodily pain dimension (SMD: 1.02; low evidence) or the impact of stroke on self-perceived health (p = 0.38).

CONCLUSION

Lower limb RT led to significant improvements in the body structure and function domain (knee extensors and flexors, leg press, global lower limb muscle strength) in individuals with chronic stroke. No improvements were found in the activity (mobility, gait [walking speed]) or participation (quality of life, impact of stroke on self-perceived health) domains.

PROSPERO REGISTRATION NUMBER

CRD42021272645.

Exercise dosage to facilitate the recovery of balance, walking, and quality of life after stroke

Background

Although aerobic training (AT) and resistance training (RT) are recommended after stroke, the optimal dosage of these interventions and their effectiveness on balance, walking capacity, and quality of life (QoL) remain conflicting.

Objectives

Our study aimed to quantify the effects of different modes, dosages and settings of exercise therapy on balance, walking capacity, and QoL in stroke survivors.

Method

PubMed, CINHAL, and Hinari databases were searched for randomised controlled trials (RCTs) evaluating the effects of AT and RT on balance, walking, and QoL in stroke survivors. The treatment effect was computed by the standard mean differences (SMDs).

Results

Twenty-eight trials (n = 1571 participants) were included. Aerobic training and RT interventions were ineffective on balance. Aerobic training interventions were the most effective in improving walking capacity (SMD = 0.37 [0.02, 0.71], p = 0.04). For walking, capacity, a higher dosage (duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve) of AT interventions demonstrated a significantly greater effect (SMD = 0.58 [0.12, 1.04], p = 0.01). Combined AT and RT improved QoL (SMD = 0.56 [0.12, 0.98], p = 0.01). Hospital located rehabilitation setting was effective for improving walking capacity (SMD = 0.57 [0.06, 1.09], p = 0.03) compared with home and/or community and laboratory settings.

Conclusion

Our findings showed that neither AT nor RT have a significant effect on balance. However, AT executed in hospital-located settings with a higher dose is a more effective strategy to facilitate walking capacity in chronic stroke. In contrast, combined AT and RT is beneficial for improving QoL.

Clinical implications

A high dosage of aerobic exercise, duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve is beneficial for improving walking capacity.

Necessity and Content of Swing Phase Gait Coordination Training Post Stroke; A Case Report

Background/Problem: Standard neurorehabilitation and gait training has not proved effective in restoring normal gait coordination for many stroke survivors. Rather, persistent gait dyscoordination occurs, with associated poor function, and progressively deteriorating quality of life. One difficulty is the array of symptoms exhibited by stroke survivors with gait deficits. Some researchers have addressed lower limb weakness following stroke with exercises designed to strengthen muscles, with the expectation of improving gait. However, gait dyscoordination in many stroke survivors appears to result from more than straightforward muscle weakness.

PURPOSE

Thus, the purpose of this case study is to report results of long-duration gait coordination training in an individual with initial good strength, but poor gait swing phase hip/knee and ankle coordination.

METHODS

Mr. X was enrolled at >6 months after a left hemisphere ischemic stroke. Gait deficits included a 'stiff-legged gait' characterized by the absence of hip and knee flexion during right mid-swing, despite the fact that he showed good initial strength in right lower limb quadriceps, hamstrings, and ankle dorsiflexors. Treatment was provided 4 times/week for 1.5 h, for 12 weeks. The combined treatment included the following: motor learning exercises designed for coordination training of the lower limb; functional electrical stimulation (FES) assisted practice; weight-supported coordination practice; and over-ground and treadmill walking. The FES was used as an adjunct to enhance muscle response during motor learning and prior to volitional recovery of motor control. Weight-supported treadmill training was administered to titrate weight and pressure applied at the joints and to the plantar foot surface during stance phase and pre-swing phase of the involved limb. Later in the protocol, treadmill training was administered to improve speed of movement during the gait cycle. Response to treatment was assessed through an array of impairment, functional mobility, and life role participation measures.

RESULTS

At post-treatment, Mr. X exhibited some recovery of hip, knee, and ankle coordination during swing phase according to kinematic measures, and the stiff-legged gait was resolved. Muscle strength measures remained essentially constant throughout the study. The modified Ashworth scale showed improved knee extensor tone from baseline of 1 to normal (0) at post-treatment. Gait coordination overall improved by 12 points according to the Gait Assessment and Intervention Tool, Six Minute Walk Test improved by 532', and the Stroke Impact Scale improved by 12 points, including changes in daily activities; mobility; and meaningful activities.

DISCUSSION

Through the combined use of motor learning exercises, FES, weight-support, and treadmill training, coordination of the right lower limb improved sufficiently to exhibit a more normal swing phase, reducing the probability of falls, and subsequent downwardly spiraling dysfunction. The recovery of lower limb coordination during swing phase illustrates what is possible when strength is sufficient and when coordination training is targeted in a carefully titrated, highly incrementalized manner. Conclusions/Contribution to the Field: This case study contributes to the literature in several ways: (1) illustrates combined interventions for gait training and response to treatment; (2) provides supporting case evidence of relationships among knee flexion coordination, swing phase coordination, functional mobility, and quality of life; (3) illustrates that strength is necessary, but not sufficient to restore coordinated gait swing phase after stroke in some stroke survivors; and (4) provides details regarding coordination training and progression of gait training treatment for stroke survivors.

Effects of Immersive and Non-Immersive Virtual Reality on the Static and Dynamic Balance of Stroke Patients: A Systematic Review and Meta-Analysis

(1) Background: The development of new technologies means that the use of virtual reality is increasingly being implemented in rehabilitative approaches for adult stroke patients.

OBJECTIVE

To analyze the existing scientific evidence regarding the application of immersive and non-immersive virtual reality in patients following cerebrovascular incidents and their efficacy in achieving dynamic and static balance. (2) Data sources: An electronic search of the databases Medline, Cochrane Library, PEDro, Scopus, and Scielo from January 2010 to December 2020 was carried out using the terms physiotherapy, physical therapy, virtual reality, immersive virtual reality, non-immersive virtual reality, stroke, balance, static balance, and dynamic balance.

SELECTION OF STUDIES

Randomized controlled trials in patients older than 18 developed with an adult population (>18 years old) with balance disorders as a consequence of suffering a stroke in the previous six months before therapeutic intervention, including exercises harnessing virtual reality in their interventions and evaluations of balance and published in English or Spanish, were included. A total of two hundred twenty-seven articles were found, ten of which were included for review and of these, nine were included in the subsequent meta-analysis. (3) Data extraction: Two authors selected the studies and extracted their characteristics (participants, interventions, and validation instruments) and results. The methodological quality of the studies was evaluated using the PEDro scale, and the risk of bias was determined using the Cochrane risk-of-bias tool.

DATA SYNTHESIS

Of the selected studies, three did not show significant improvements and seven showed significant improvements in the intervention groups in relation to the variables. (4) Conclusions: Non-immersive virtual reality combined with conventional rehabilitation could be considered as a therapeutic option.

The Effect of Intensity, Frequency, Duration and Volume of Physical Activity in Children and Adolescents on Skeletal Muscle Fitness: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Physical activity could improve the muscle fitness of youth, but the systematic analysis of physical activity elements and muscle fitness was limited. This systematic review and meta-analysis aim to explore the influence of physical activity elements on muscle fitness in children and adolescents. We analyzed literature in Embase, EBSCO, Web of Science, and PubMed databases from January 2000 to September 2020. Only randomized controlled studies with an active control group, which examined at least 1 muscle fitness evaluation index in individuals aged 5–18 years were included. Articles were evaluated using the Jaded scale. Weighted-mean standardized mean differences (SMDs) were calculated using random-effects models. Twenty-one studies and 2267 subjects were included. Physical activity had moderate effects on improving muscle fitness (SMD: 0.58–0.96, p < 0.05). Physical activity element subgroup analysis showed that high-intensity (SMD 0.68–0.99, p < 0.05) physical activity <3 times/week (SMD 0.68–0.99, p < 0.05), and <60 min/session (SMD 0.66–0.76, p < 0.01) effectively improved muscle fitness. Resistance training of ≥3 sets/session (SMD 0.93–2.90, p < 0.01) and <10 repetitions/set (SMD 0.93–1.29, p < 0.05) significantly improved muscle fitness. Low-frequency, high-intensity, and short-duration physical activity more effectively improves muscle fitness in children and adolescents. The major limitation of this meta-analysis was the low quality of included studies. The study was registered in PROSPERO with the registration number CRD42020206963 and was funded mainly by the Ministry of Education of Humanities and Social Science project, China.

Effects of resistance training on metabolic and cardiovascular responses to a maximal cardiopulmonary exercise test in Parkinson`s disease

Objective:

To evaluate the effects of resistance training on metabolic and cardiovascular responses during maximal cardiopulmonary exercise testing in patients with Parkinson’s disease.

Methods:

Twenty-four patients with Parkinson’s disease (modified Hoehn and Yahr stages 2 to 3) were randomly assigned to one of two groups: Control or Resistance Training. Patients in the Resistance Training Group completed an exercise program consisting of five resistance exercises (two to four sets of six to 12 repetitions maximum per set) twice a week. Patients in the Control Group maintained their usual lifestyle. Oxygen uptake, systolic blood pressure and heart rate were assessed at rest and during cycle ergometer-based maximal cardiopulmonary exercise testing at baseline and at 12 weeks. Assessments during exercise were conducted at absolute submaximal intensity (slope of the linear regression line between physiological variables and absolute workloads), at relative submaximal intensity (anaerobic threshold and respiratory compensation point) and at maximal intensity (maximal exercise). Muscle strength was also evaluated.

Results:

Both groups had similar increase in peak oxygen uptake after 12 weeks of training. Heart rate and systolic blood pressure measured at absolute and relative submaximal intensities and at maximal exercise intensity did not change in any of the groups. Muscle strength increased in the Resistance Training but not in the Control Group after 12 weeks.

Conclusion:

Resistance training increases muscle strength but does not change metabolic and cardiovascular responses during maximal cardiopulmonary exercise testing in patients with Parkinson’s disease without cardiovascular comorbidities.

Letter to the Editor: Exercise Interventions and Cardiovascular Health in Childhood Cancer: A Meta-Analysis

Dear Editor,International Journal of Sports MedicineThe analysis of the study entitled "Exercise Interventions and Cardiovascular Health in Childhood Cancer: a Meta-Analysis" 1 was very interesting. The authors of this meta-analysis aimed to summarize the evidence on the effects of physical training intervention over three weeks on cardiovascular and cardiorespiratory outcomes in childhood cancer survivors (CCS). In addition, they addressed endpoints related not only to cardiac structure and function, but also to cardiorespiratory fitness.

Evaluation of the Lower Limb Muscles' Electromyographic Activity during the Leg Press Exercise and Its Variants: A Systematic Review

The aim of this study was to analyze the literature on muscle activation measured by surface electromyography (sEMG) of the muscles recruited when performing the leg press exercise and its variants. The Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to report this review. The search was carried out using the PubMed, Scopus, and Web of Science electronic databases. The articles selected met the following inclusion criteria: (a) a cross-sectional or longitudinal study design; (b) neuromuscular activation assessed during the leg press exercise, or its variants; (c) muscle activation data collected using sEMG; and (d) study samples comprising healthy and trained participants. The main findings indicate that the leg press exercise elicited the greatest sEMG activity from the quadriceps muscle complex, which was shown to be greater as the knee flexion angle increased. In conclusion, (1) the vastus lateralis and vastus medialis elicited the greatest muscle activation during the leg press exercise, followed closely by the rectus femoris; (2) the biceps femoris and the gastrocnemius medialis showed greater muscular activity as the knee reached full extension, whereas the vastus lateralis and medialis, the rectus femoris, and the tibialis anterior showed a decreasing muscular activity pattern as the knee reached full extension; (3) evidence on the influence of kinematics modifications over sEMG during leg press variants is still not compelling as very few studies match their findings.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

Resistance training in stroke rehabilitation: systematic review and meta-analysis

Objective:

This systematic review and meta-analysis investigates the effects of resistance training in supporting the recovery in stroke patients.

Data sources:

PubMed, the Cochrane Central Register of Controlled Trials and the PEDro databases were reviewed up to 30 April 2020.

Review methods:

Randomized controlled trials were included, who compared: (i) resistance training with no intervention, (ii) resistance training with other interventions and (iii) different resistance training protocols in stroke rehabilitation.

Results:

Overall 30 trials ( n = 1051) were enrolled. The parameters evaluated were: (1) gait, (2) muscular force and motor function, (3) mobility, balance and postural control, (4) health related quality of life, independence and reintegration, (5) spasticity and hypertonia, (6) cardiorespiratory fitness, (7) cognitive abilities and emotional state and (8) other health-relevant physiological indicators. The data indicates that: (i) resistance training is beneficial for the majority of parameters observed, (ii) resistance training is superior to other therapies on muscular force and motor function of lower and upper limbs, health related quality of life, independence and reintegration and other health-relevant physiological indicators, not significantly different from other therapies on walking ability, mobility balance and postural control and spasticity and hypertonia, and inferior to ergometer training on cardiorespiratory fitness and (iii) the type of resistance training protocol significantly impacts its effect; leg press is more efficient than knee extension and high intensity training is superior than low intensity training.

Conclusion:

Current data indicates that resistance training may be beneficial in supporting the recovery of stroke patients. However, the current evidence is insufficient for evidence-based rehabilitation.

A Head-to-Head Comparison of an Isometric and a Concentric Fatigability Protocol and the Association With Fatigue and Walking in Persons With Multiple Sclerosis

Background. Fatigue is one of the most frequent symptoms in persons with multiple sclerosis (MS). Distinction is made between subjective perceptions of fatigue and objective measures of fatigability. Fatigability can be measured by different protocols. Yet no studies have compared isometric and concentric contraction protocols of the lower extremities head-to-head. Therefore, the purpose of the present study was to (1) compare 2 such protocols head-to-head and (2) to investigate the association between fatigability evoked by the 2 protocols and measures of fatigue and walking. Methods. A total of 45 patients with MS had their walking capacity measured objectively by the 6-minute walk test (6MWT) and subjectively by the 12-item Multiple Sclerosis Walking Scale (MSWS-12). Fatigue was measured by the Modified Fatigue Impact Scale (MFIS) and fatigability by 2 knee extension protocols: sustained isometric and concentric. Results. The sustained isometric protocol induced a higher degree of fatigability than the concentric protocol ( P < .01). Regression analyses revealed that sustained isometric fatigability was not associated with either measures of fatigue or walking (all r2 = 0.00; P = .85-.99), whereas the concentric protocol was significantly associated with fatigue ( r2 = 0.20; P < .01), 6MWT ( r2 = 0.09; P < .05), and MSWS-12 ( r2 = 0.16; P < .01). Furthermore, after adjusting for maximal strength and sex, concentric fatigability remained a strong and significant predictor of fatigue (β = 0.49) and walking (6MWT: β = −0.26; MSWS: β = 0.37). Conclusion. This study provides the first evidence that a lower-extremity concentric fatigability protocol provides superior reflection of both fatigue and walking when compared with a sustained isometric protocol. We suggest that concentric protocols should be the focus of future studies investigating fatigability.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical activity and physical fitness are low after stroke. Interventions to increase physical fitness could reduce mortality and reduce disability through increased function.

OBJECTIVES

The primary objectives of this updated review were to determine whether fitness training after stroke reduces death, death or dependence, and disability. The secondary objectives were to determine the effects of training on adverse events, risk factors, physical fitness, mobility, physical function, health status and quality of life, mood, and cognitive function.

SEARCH METHODS

In July 2018 we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, and four additional databases. We also searched ongoing trials registers and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 75 studies, involving 3017 mostly ambulatory participants, which comprised cardiorespiratory (32 studies, 1631 participants), resistance (20 studies, 779 participants), and mixed training interventions (23 studies, 1207 participants). Death was not influenced by any intervention; risk differences were all 0.00 (low-certainty evidence). There were few deaths overall (19/3017 at end of intervention and 19/1469 at end of follow-up). None of the studies assessed death or dependence as a composite outcome. Disability scores were improved at end of intervention by cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% CI 0.19 to 0.84; 8 studies, 462 participants; P = 0.002; moderate-certainty evidence) and mixed training (SMD 0.23, 95% CI 0.03 to 0.42; 9 studies, 604 participants; P = 0.02; low-certainty evidence). There were too few data to assess the effects of resistance training on disability. Secondary outcomes showed multiple benefits for physical fitness (VO2 peak and strength), mobility (walking speed) and physical function (balance). These physical effects tended to be intervention-specific with the evidence mostly low or moderate certainty. Risk factor data were limited or showed no effects apart from cardiorespiratory fitness (VO2 peak), which increased after cardiorespiratory training (mean difference (MD) 3.40 mL/kg/min, 95% CI 2.98 to 3.83; 9 studies, 438 participants; moderate-certainty evidence). There was no evidence of any serious adverse events. Lack of data prevents conclusions about effects of training on mood, quality of life, and cognition. Lack of data also meant benefits at follow-up (i.e. after training had stopped) were unclear but some mobility benefits did persist. Risk of bias varied across studies but imbalanced amounts of exposure in control and intervention groups was a common issue affecting many comparisons.

AUTHORS' CONCLUSIONS

Few deaths overall suggest exercise is a safe intervention but means we cannot determine whether exercise reduces mortality or the chance of death or dependency. Cardiorespiratory training and, to a lesser extent mixed training, reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve fitness, balance and the speed and capacity of walking. The magnitude of VO2 peak increase after cardiorespiratory training has been suggested to reduce risk of stroke hospitalisation by ˜7%. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription, the range of benefits and any long-term benefits.

Safety of Performing a Graded Exercise Test Early after Stroke and Transient Ischemic Attack

BACKGROUND

Low cardiorespiratory fitness (CRF) is a predictor of stroke risk and poor outcome poststroke. Fitness levels are rarely assessed in the acute phase and it is unclear if it is safe for stroke survivors and people with transient ischemic attack (TIA) to perform a graded exercise test to assess fitness.

OBJECTIVE

To determine if people within 14 days post stroke can safely perform a graded exercise test.

DESIGN

Observational study.

SETTING

Research institute.

PARTICIPANTS

People with stroke or TIA admitted to an acute stroke unit.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Safety of performing a graded exercise test early post stroke. Safety outcomes were (1) occurrence of an adverse event or (2) <85% blood oxygen saturation (SpO₂ ). Participants performed a graded exercise test on a recumbent stepper at a research institute <2 weeks postevent. CRF was determined by measuring peak volume of oxygen uptake (VO_2peak ) using a metabolic cart.

RESULTS

Twenty-nine participants were enrolled in the study (median age 69 years; interquartile range 58-75). Sixteen were diagnosed with TIA and 13 with a mild stroke. Twenty-eight participants completed the test; one participant was unable to perform the test due to back pain. The test was terminated due to standardized stopping criteria in 26 cases (5 = volitional fatigue, 6 = unable to keep required cadence, 15 = reaching 85% HR_max ), one due to safety (ie, SpO₂  < 85%), and one was inadvertently terminated before stopping criteria were reached. Average CRF determined by the exercise test was low; mean VO_2peak of 16.2 ± 4.5 mL/kg/min for men (n = 20) and 12.4 ± 3.6 mL/kg/min for women (n = 8).

CONCLUSIONS

Determining exercise capacity early post stroke and TIA using a graded exercise test appears to be safe in patients with mild deficits. This information should be useful to plan tailored exercise programs. Further research should focus on determining safety of exercise testing in more severely affected stroke survivors.

The Comparison between Isokinetic Knee Muscles Strength in the Ipsilateral and Contralateral Limbs and Correlating with Function of Patients with Stroke

Objective The aim of this study is to compare the isokinetic knee muscles peak torque measurements and proprioception between the affected and intact limbs of patients with stroke, in addition to finding the correlation between knee muscles strength and lower limb function. Methods Twelve patients with stroke (mean age 64.33 ± 6.140 years), with 3 to 7 months poststroke who can walk 25 feet independently without using or using assistive devices and full passive range of motion were included in the study. Biodex isokinetic dynamometer was used for measuring isokinetic strength at 90°/s, 120°/s, and 150°/s and isometric strength at 60°/s in both flexors and extensors of the knee, whereas proprioception was measured at 45°/s knee flexion, all for affected and intact limbs. Functional measurements were assessed using the Fugl-Meyer Assessment for Lower Limb scale and Barthel Index (BI). Results The differences shown were found to be statistically significant between affected and intact limbs in isokinetic 90°/s flexion ( p = 0.005), extension ( p = 0.0013), and isometric at 60°/s flexion ( p < 0.0001) knee muscle strengths and also the proprioception ( p = 0.05). Significant positive correlation was found between isokinetic affected side knee flexion at 90°/s ( r = 0.903) with BI ( r = 0.704). Conclusion There is a significant difference in peak torque measurements between affected and normal lower limbs of poststroke patients, as well as a significant correlation between the knee strength and lower limb functions. Furthermore, it can also be concluded that the differences in knee proprioception between the affected and intact limbs were shown to be significant.

Cross-sectional study of quadriceps properties and postural stability in patients with chronic stroke and limited vs. non-limited community ambulation

Background: Changes in the paretic-side metabolism post-stroke and quadriceps muscle mechanical properties favour muscle wasting, affecting postural instability and walking impairment. Further clarification is needed in subjects post-stroke who show limited or non-limited community ambulation. Objectives: To analyze between-limb differences in quadriceps muscle thickness, strength and thigh cutaneous temperature, as well as investigate postural stability in subjects with chronic stroke and limited vs. non-limited community ambulation and compared against healthy controls. Methods: In this controlled cross-sectional study, 26 participants with chronic hemiparesis post-stroke (divided in a slow gait group (SG<0.8 m/s) (n = 13) and a fast gait group with full community ambulation speed (FG≥0.8 m/s)) and 18 healthy people were recruited. Thigh surface temperature, rectus femoris (RF) and vastus intermedius (VI) muscles thickness, quadriceps' isometric maximal voluntary contraction and postural stability were measured. Results: The SG presented significantly lower RF (P = .019) and VI (P = .006) muscle thickness, less peak force (P < .001) and lower temperature (P = .002) in the paretic vs the non-paretic limb. The FG showed significantly lower VI thickness (P = .036) and peak force (P < .001) in the paretic vs the non-paretic limb. Regarding balance, all indices were worse in the SG versus the FG and CG. Conclusions: Subjects of the FG, despite showing full community ambulation speed, had less quadriceps strength and VI muscle thickness but not RF muscle wasting in the paretic limb. The paretic VI muscle wasting may be an important factor to reach normal walking. The SG showed between-limb differences in all the studied variables and the worst postural stability.

Analysis of trunk rolling in Parkinson's disease patients using a mattress mobility detection system

BACKGROUND AND OBJECTIVE

Parkinson's disease (PD) is a neurodegenerative condition characterized by motor dysfunction and various types of non-motor impairments. The reaction time and movement time are reported to become more severe delayed in worse PD patients. Most tools for evaluating motor impairment are limited by relying on subjective observations and being qualitative in design. The aim of this study was to investigate trunk rolling performance in PD patients by using a recently developed system to detect turning in bed.

METHODS

The study included 20 PD patients and 42 healthy controls. A mattress mobility detection system was employed for quantitative measurements. Each test session consisted of subjects starting by lying in a supine position on a bed and rolling 10 times onto their left side and 10 times onto their right side. Strain gauges mounted under the feet of the bed recorded changes in the center of pressure (CoP).

RESULTS

For turning back, the patients compared with the controls had significantly longer movement time (P = 0.017), longer time to peak counteraction (P = 0.001), larger ratio of peak counteraction to movement time (P = 0.006), shorter CoP displacement (P < 0.0001), slower turning speed (P = 0.000), weaker peak counteraction (P = 0.013), and smaller ratio of peak counteraction to weight (P = 0.032). Results for turning over were similar except there was no significant difference in the ratio of peak counteraction to weight.

CONCLUSIONS

The mattress mobility detection system was useful for objectively assessing trunk rolling performance of PD patients. Improved assessment of trunk function in PD patients could lead to better treatments and improved rehabilitation procedures.

Resistance Training and Stroke: A Critical Analysis of Different Training Programs

The aim of this study was to carry out a literature review on the overall benefits of resistance training (RT) after stroke and undertake a critical analysis of the resistance exercise programs surveyed (rest interval between sets and exercises, number of sets, number of repetitions, intensity, duration of training, and weekly frequency). To obtain articles for the review, we searched PubMed, Google Scholar, and Physiotherapy Evidence Database (PEDro). Inclusion criteria were considered using the PICO (population, intervention, control/comparison, and outcome variables) model. The following characteristics were recorded for all articles: type of study, author, year of publication, participants (time after stroke, sample size, and age), benefits of RT, and structured resistance exercise programs. Positive effects of training were found on anxiety status, quality of life, muscle hypertrophy, cognitive function, strength, and muscle power. Only 5 studies described the main variables of RT in detail. Lack of control of some variables of RT may negatively affect the results of this practice. The findings of the present study may further inform health and physical conditioning professionals on the importance and necessity of using the main variables in the search for benefits for individuals with stroke.

Cyclical blood flow restriction resistance exercise: a potential parallel to remote ischemic preconditioning?

Remote ischemic preconditioning (RIPC) is characterized by the cyclical application of limb blood flow restriction and reperfusion and has been shown to protect vital organs during a subsequent ischemic insult. Blood flow restriction exercise (BFRE) similarly combines bouts of blood flow restriction with low-intensity exercise and thus could potentially emulate the protection demonstrated by RIPC. One concern with BFRE, however, is the potential for an augmented rise in sympathetic outflow due to greater activation of the exercise pressor reflex. Because of the use of lower workloads, however, we hypothesized that BFRE would elicit an attenuated increase in sympathetic outflow [assessed via plasma norepinephrine (NE) and mean arterial pressure (MAP)] and middle cerebral artery velocity (MCAv) when compared with conventional exercise (CE). Fifteen subjects underwent two leg press exercise interventions: 1) BFRE-220 mmHg bilateral thigh occlusion at 20% 1 rep-max (1RM), and 2) CE-65% 1RM without occlusion. Each condition consisted of 4 × 5-min cycles of exercise, with 3 × 10-reps in each cycle. Five minutes of rest and reperfusion (for BFRE) followed each cycle. MAP increased with exercise (P < 0.001) and was 4-5 mmHg higher with CE versus BFRE (P ≤ 0.09). Mean MCAv also increased with exercise (P < 0.001) and was higher with CE compared with BFRE during the first bout of exercise only (P = 0.07). Plasma NE concentration increased with CE only (P < 0.001) and was higher than BFRE throughout exercise (P ≤ 0.02). The attenuated sympathetic response, combined with similar cerebrovascular responses, suggest that cyclical BFRE could be explored as an alternative to CE in the clinical setting.

POWER training in chronic stroke individuals: differences between responders and nonresponders

BACKGROUND

Lower extremity muscle weakness is a primary contributor to post-stroke dysfunction. Resistance training is an effective treatment for hemiparetic weakness and improves walking performance. Post-stroke subject characteristics that do or do not improve walking speed following resistance training are unknown.

OBJECTIVE

The purpose of this paper was to describe baseline characteristics, as well as responses to training, associated with achieving a minimal clinically important difference (MCID) in walking speed (≥0.16 m/s) following Post-stroke Optimization of Walking Using Explosive Resistance (POWER) training.

METHODS

Seventeen participants completed 24 sessions of POWER training, which included intensive progressive leg presses, jump training, calf raises, sit-to-stands, step-ups, and over ground fast walking. Outcomes included SSWS, FCWS, DGI, FMA-LE, 6-MWT, paretic knee power, non-paretic knee power, and paretic step ratio.

RESULTS

Specific to those who reached MCID in SSWS (e.g. "responders"), significant improvements in SSWS, FCWS, 6-MWT, paretic knee power, and non-paretic knee power was realized. Paretic knee power and non-paretic knee power significantly improved in those who did not achieve MCID for gait speed (e.g. "non-responders").

CONCLUSION

The potential for POWER training to enhance general locomotor function was confirmed. Baseline paretic knee strength/power may be an important factor in how an individual responds to this style of training. The lack of change within the non-responders emphasizes the contribution of factors other than lower extremity muscle power improvement to locomotor dysfunction.

Clinical Evidence of Exercise Benefits for Stroke

Even though stroke is the third, not the first, most common cause of disability-adjusted life years in developed countries, it is one of the most expensive to treat. Part of the expense is due to secondary problems in the post-stroke period including: cognition, memory, attention span, pain, sensation loss, psychological issues, and problems with mobility and balance. Research has identified that exercise has both positive physical and psychosocial effects for post-stroke patients. Therefore, this scientific statement provides an overview on exercise rehabilitation for post-stroke patients.We will use systematic literature reviews, clinical and epidemiology reports, published morbidity and mortality studies, clinical and public health guidelines, patient files, and authoritative statements to support this overview.Evidence clearly supports the use of various kinds of exercise training (e.g., aerobic, strength, flexibility, neuromuscular, and traditional Chinese exercise) for stroke survivors. Aerobic exercise, the main form of cardiac rehabilitation, may play an important role in improving aerobic fitness, cardiovascular fitness, cognitive abilities, walking speed and endurance, balance, quality of life, mobility, and other health outcomes among stroke patients. Strength exercise, included in national stroke guidelines and recommended for general health promotion for stroke survivors, can lead to improvements in functionality, psychosocial aspects, and quality of life for post-stroke patients. Flexibility exercises can relieve muscle spasticity problems, improve motor function, range of motion, and prevent contractures. Stretching exercises can also prevent joint contractures, muscle shortening, decrease spasticity, reduce joint stiffness and improve a post-stroke patient's overall function. Neuromuscular exercises can improve activities of daily living (ADL) through coordination and balance activities. Traditional Chinese exercises are used to improve walking and balance ability as well as increase muscle strength, which is important for post-stroke patients.The present evidence strongly supports the power of exercise for post-stroke patients, which in this study combined aerobic exercises, strength training, flexibility exercises, neuromuscular exercises, and traditional Chinese exercises. This research can encourage post-stroke survivors to consider the importance of exercise in the rehabilitation process.