Deficits in motor coordination of the paretic lower limb best explained activity limitations after stroke

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.

The Effects of Shock Wave Therapy on Spasticity and Walking Ability in People with Stroke: A Comparative Study of Different Application Sites

BACKGROUND

This study was conducted to investigate the effects of extracorporeal shock wave therapy on the improvement of walking ability through a reduction in spasticity in stroke patients.

METHODS

Thirty-three patients diagnosed with ischemic stroke by a rehabilitation medicine specialist were randomly assigned to three groups. The patients were divided into experimental group 1 in which shock waves were applied to the muscle-tendon junction, experimental group 2 in which shock waves were applied to the middle of the muscle, and experimental group 3 in which shock waves were applied to both the muscle-tendon junction and the middle of the muscle. The MAS was used to evaluate spasticity in the subjects, and the Dartfish software was used to measure knee and ankle angles during heel-off when walking.

RESULTS

Based on the results of the study, a significant decrease in spasticity and increased joint angles were found in experimental groups 1 and 3 compared to experimental group 2, and the change in joint angle was significantly greater in experimental group 3 than in experimental groups 1 and 2.

CONCLUSIONS

These results indicate that treatment effect may vary depending on the application site of the shock wave, and to obtain the best treatment effect, the shock wave should be applied to both the muscle-tendon junction and the middle part of the muscle.

How Do Motor and Sensory Function Correlate with Daily Performance Recovery after Post-Stroke Robotic Intervention? A Secondary Analysis of a Non-Randomized Controlled Trial

New technologies have been developed to complement conventional interventions to better target the specific needs of people with stroke, and they have been shown to improve both function and performance. However, it is unknown whether the baseline levels of sensorimotor function and performance interrelate with the improvement in upper limb and daily performance. Thus, the aim of this study was to examine the relationship between baseline levels of sensorimotor function and daily performance and its impact on post-intervention improvement in people with stroke following a robotic intervention. A single-blind, non-randomized, controlled clinical trial was conducted. Participants in the experimental group (n = 9) received a robotic intervention in addition to conventional treatment. Sensorimotor function was measured with Semmes-Weinstein Monofilaments® and the Fugl-Meyer Assessment Upper Extremity Scale. Upper limb and daily performance were measured with the MAL and SIS-16 scales. The multivariate regression models showed that baseline levels of upper limb performance and motor function predicted >95% of the variance in upper limb performance (p < 0.001), while pre-intervention levels of daily performance explained >75% of the post-intervention variance (p < 0.05). These findings indicate that basal upper limb motor function is associated with improved performance following a combined intervention of conventional treatment and robotic intervention.

A Robot-Assisted Therapy to Increase Muscle Strength in Hemiplegic Gait Rehabilitation

This study examines the feasibility of using a robot-assisted therapy methodology based on the Bobath concept to perform exercises applied in conventional therapy for gait rehabilitation in stroke patients. The aim of the therapy is to improve postural control and movement through exercises based on repetitive active-assisted joint mobilization, which is expected to produce strength changes in the lower limbs. As therapy progresses, robotic assistance is gradually reduced and the patient's burden increases with the goal of achieving a certain degree of independence. The relationship between force and range of motion led to the analysis of both parameters of interest. The study included 23 volunteers who performed 24 sessions, 2 sessions per week for 12 weeks, each lasting about 1 h. The results showed a significant increase in hip abduction and knee flexion strength on both sides, although there was a general trend of increased strength in all joints. However, the range of motion at the hip and ankle joints was reduced. The usefulness of this platform for transferring exercises from conventional to robot-assisted therapies was demonstrated, as well as the benefits that can be obtained in muscle strength training. However, it is suggested to complement the applied therapy with exercises for the maintenance and improvement of the range of motion.

The Relationship Between Strength of the Affected Leg and Walking Speed After Stroke Varies According to the Level of Walking Disability: A Systematic Review

OBJECTIVE

The objectives of this review were to determine the relationship between muscle strength of the affected leg and walking speed after stroke and whether this relationship varied according to muscle group or level of walking disability.

METHODS

This systematic review with meta-analysis focused on observational studies of adult survivors of stroke. Muscle strength had to be measured as maximum voluntary force production during an isometric contraction of the affected leg. Walking had to be measured as walking speed. Studies had to report correlations between muscle strength and walking speed.

RESULTS

Thirty studies involving 1001 participants were included. Pooled mean correlations between muscle strength of the affected leg and walking speed was 0.51 (95% CI = 0.45 to 0.57). Pooled correlations between the strength of individual muscle groups and walking speed ranged from 0.42 (for the hip abductors) to 0.57 (for the ankle dorsiflexors). The correlation between level of walking disability and the mean correlation between muscle strength and walking speed was -0.70 (95% CI = -0.42 to -0.86).

CONCLUSION

After stroke, there is a strong relationship between strength of the affected leg and walking speed, with little variability across individual muscle groups. However, the level of walking disability of people with stroke does make a difference such that the more disabled people are, the stronger the relationship is between strength of the affected leg and walking speed.

IMPACT

This study suggests that the strength of all muscles of the affected leg is important for walking after stroke. It appears that increasing strength in the affected leg could be most important in people who are more disabled.

LAY SUMMARY

After stroke, the speed at which a person can walk is highly associated with the muscle strength of their affected leg. In people whose walking speed is severely affected, this association is stronger, and the physical therapist might focus on strengthening that leg so the individual can walk faster.

Virtual Reality and Physiotherapy in Post-Stroke Functional Re-Education of the Lower Extremity: A Controlled Clinical Trial on a New Approach

Numerous Virtual Reality (VR) systems address post-stroke functional recovery of the lower extremity (LE), most of them with low early applicability due to the gait autonomy they require. The aim of the present study was to evaluate the feasibility of a specific VR treatment and its clinical effect on LE functionality, gait, balance, and trunk control post-stroke. A controlled, prospective, clinical trial was carried out with 20 stroke patients, who were divided into two groups: the first group (VR + CP; n = 10) received combined therapy of 1 h VR and 1 h of conventional physiotherapy (CP) and the second group (CP; n = 10) received 2 h of CP (5 days/week, for 3 weeks). The following pre-post-intervention measuring scales were used: Functional Ambulatory Scale (FAC), Functional Independence Measure (FIM), Fugl-Meyer Assessment (FM), Berg Balance Scale (BBS), and Trunk Control Test (TCT). Only VR + CP showed a significant improvement in FAC. In FIM, CP presented a tendency to significance, whereas VR + CP showed significance. Both groups improved significantly in FM (especially in amplitude/pain in VR + CP and in sensitivity in CP) and in BBS. In TCT, there was a non-significant improvement in both groups. The results indicate that the intervention with VR is a feasible treatment in the post-stroke functional re-education of the LE, with the potential to be an optimal complement of CP.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prediction of Independent Walking in People Who Are Nonambulatory Early After Stroke: A Systematic Review

BACKGROUND AND PURPOSE

One systematic review has examined factors that predict walking outcome at one month in initially nonambulatory patients after stroke. The purpose of this systematic review was to examine, in nonambulatory people within a month of stroke, which factors predict independent walking at 3, 6, and 12 months.

METHODS

Prognostic factors: Any factors measured within one month after stroke with the aim of predicting independent walking. Outcome of interest: Independent walking defined as walking with or without an aid but with no human assistance.

RESULTS

Fifteen studies comprising 2344 nonambulatory participants after stroke were included. Risk of bias was low in 7 studies and moderate in 8 studies. Individual meta-analyses of 2 to 4 studies were performed to calculate the pooled estimate of the odds ratio for 12 prognostic factors. Younger age (odds ratio [OR], 3.4, P<0.001), an intact corticospinal tract (OR, 8.3, P<0.001), good leg strength (OR, 5.0, P<0.001), no cognitive impairment (OR, 3.5, P<0.001), no neglect (OR, 2.4, P=0.006), continence (OR, 2.3, P<0.001), good sitting (OR, 7.9, P<0.001), and independence in activities of daily living (OR 10.5, P<0.001) predicted independent walking at 3 months. Younger age (OR, 2.1, P<0.001), continence (OR, 13.8, P<0.001), and good sitting (OR, 19.1, P<0.001) predicted independent walking at 6 months. There were insufficient data at 12 months.

CONCLUSIONS

Younger age, an intact corticospinal tract, good leg strength, continence, no cognitive impairment, no neglect, good sitting, and independence in activities of daily living in patients who are nonambulatory early after stroke predict independent walking at 3 months. Registration: URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42018108794.

Correlation of paretic knee extension strength with gait speed after stroke: A meta-analysis

BACKGROUND AND OBJECTIVE: Numerous studies have addressed the relationship between paretic knee extension strength and comfortable walking speed after stroke. However, the correlations reported are highly variable. This review sought to summarize the correlational data using meta-analysis. METHODS: Relevant literature was identified via a search of 3 bibliographic databases. Articles were screened and perused for inclusion. Included articles were examined for information on the sample studied, procedures for measuring strength and gait speed, and correlations reported between the 2 variables. Meta-analysis was used to calculate a summary correlation. RESULTS: Of 299 unique articles, 18 met inclusion criteria. Articles were diverse in regard to samples studied, procedures described, and correlations reported. Meta-analysis using data from all included studies revealed a summary correlation of 0.51. For studies using hand-held or isokinetic dynamometry, the summary correlation was 0.46 and 0.59 respectively. CONCLUSIONS: This study provides a better indication of the correlation between paretic knee extension strength and comfortable gait speed than individual studies. The correlation is high enough to provide support for the routine measurement of paretic knee extension force for individuals who have experienced a stroke.

Relationship between lower limb coordination and walking speed after stroke: an observational study

BACKGROUND

Although lower limb muscle strength is associated with walking performance in people after stroke, even when there is good strength, walking speed may remain slower than normal, perhaps due to incoordination.

OBJECTIVE

The aim of this study was to examine the relationship between walking speed and lower limb coordination in people with good strength after stroke.

METHODS

An observational study was conducted with 30 people with stroke and 30 age-matched controls. Inclusion criteria for stroke were good lower limb strength (i.e., ≥Grade 4) and walking speed at >0.6m/s without aids in bare feet (with recruitment stratified so that walking speed was evenly represented across the range). Walking performance was measured as speed during the 10-m Walk Test and distance during the 6-min Walk Test. Coordination was measured using the Lower Extremity Motor Coordination Test and reported in taps/s.

RESULTS

Stroke survivors walked at 1.00 (SD 0.26) m/s during the10-m Walk Test (64% of normal), walked 349 (SD 94) m during the 6-min Walk Test (68% of normal), and performed the Lower Extremity Motor Coordination Test at 1.20 (SD 0.34) taps/s with the affected side (64% of normal). Lower Extremity Motor Coordination Test scores for the affected side were statistically significantly correlated with walking performance in the 10-m Walk Test (r=0.42, p=0.02) and the 6-min Walk Test (r=0.50, p=0.01).

CONCLUSION

Coordination was related to walking performance, suggesting that loss of coordination may contribute to slow walking in this group of stroke survivors with good strength.

TRIAL REGISTRATION

ANZCTR12614000856617 (www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366827).