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Lando A, Cacciante L, Mantineo A, Baldan F, Pillastrini P, Turolla A, Pregnolato G. Multi-Modal versus Uni-Modal Treatment for the Recovery of Lower Limb Motor Function in Patients after Stroke: A Systematic Review with Meta-Analysis. Healthcare (Basel) 2024; 12:189. [PMID: 38255077 PMCID: PMC10815740 DOI: 10.3390/healthcare12020189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
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.
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Affiliation(s)
- Alex Lando
- Rehabilitation Unit, Department of Neuroscience, General Hospital—University of Padova, 35128 Padova, Italy;
| | - Luisa Cacciante
- Laboratory of Healthcare Innovation Technology, IRCCS San Camillo Hospital, 30126 Venice, Italy; (A.M.); (G.P.)
| | - Alessio Mantineo
- Laboratory of Healthcare Innovation Technology, IRCCS San Camillo Hospital, 30126 Venice, Italy; (A.M.); (G.P.)
| | | | - Paolo Pillastrini
- Department of Biomedical and Neuromotor Sciences, Alma Mater University of Bologna, 40128 Bologna, Italy; (P.P.); (A.T.)
- Unit of Occupational Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Andrea Turolla
- Department of Biomedical and Neuromotor Sciences, Alma Mater University of Bologna, 40128 Bologna, Italy; (P.P.); (A.T.)
- Unit of Occupational Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giorgia Pregnolato
- Laboratory of Healthcare Innovation Technology, IRCCS San Camillo Hospital, 30126 Venice, Italy; (A.M.); (G.P.)
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Mixed circuit training acutely reduces arterial stiffness in patients with chronic stroke: a crossover randomized controlled trial. Eur J Appl Physiol 2023; 123:121-134. [PMID: 36205814 DOI: 10.1007/s00421-022-05061-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 09/30/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Investigate whether a single bout of mixed circuit training (MCT) can elicit changes in arterial stiffness in patients with chronic stroke. Second, to assess the between-day reproducibility of post-MCT arterial stiffness measurements. METHODS Seven participants (58 ± 12 years) performed a non-exercise control session (CTL) and two bouts of MCT on separate days in a randomized counterbalanced order. The MCT involved 3 sets of 15 repetition maximum for 10 exercises, with each set separated by 45-s of walking. Brachial-radial pulse wave velocity (br-PWV), radial artery compliance (AC) and reflection index (RI1,2) were assessed 10 min before and 60 min after CTL and MCT. Ambulatory arterial stiffness index (AASI) was calculated from 24-h recovery ambulatory blood pressure monitoring. RESULTS Compared to CTL, after 60 min of recovery from the 1st and 2nd bouts of MCT, lower values were observed for br-PWV (mean diff = - 3.9 and - 3.7 m/s, respectively, P < 0.01; ICC2,1 = 0.75) and RI1,2 (mean diff = - 16.1 and - 16.0%, respectively, P < 0.05; ICC2,1 = 0.83) concomitant with higher AC (mean diff = 1.2 and 1.0 × 10-6 cm5/dyna, respectively, P < 0.01; ICC2,1 = 0.40). The 24-h AASI was reduced after bouts of MCT vs. CTL (1st and 2nd bouts of MCT vs. CTL: mean diff = - 0.32 and - 0.29 units, respectively, P < 0.001; ICC2,1 = 0.64). CONCLUSION A single bout of MCT reduces arterial stiffness during laboratory (60 min) and ambulatory (24 h) recovery phases in patients with chronic stroke with moderate-to-high reproducibility. TRIAL REGISTRATION Ensaiosclinicos.gov.br identifier RBR-5dn5zd.
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Amanzonwé ER, Tedesco Triccas L, Codjo L, Hansen D, Feys P, Kossi O. Exercise dosage to facilitate the recovery of balance, walking, and quality of life after stroke. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2023; 79:1846. [PMID: 36873960 PMCID: PMC9982519 DOI: 10.4102/sajp.v79i1.1846] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/09/2022] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Elogni R Amanzonwé
- Unit of NeuroRehabilitation, Department of Neurology NeuroRehabilitation, University of Parakou, Parakou, Benin.,REVAL, Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
| | - Lisa Tedesco Triccas
- REVAL, Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
| | - Léopold Codjo
- Department of Cardiology, Faculty of Medicine, University of Parakou, Parakou, Benin
| | - Dominique Hansen
- REVAL, Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium.,Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Peter Feys
- REVAL, Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
| | - Oyéné Kossi
- REVAL, Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium.,Unit of NeuroRehabilitation, Department of Neurology NeuroRehabilitation, University Hospital of Parakou, Parakou, Benin.,ENATSE, National School of Public Health and Epidemiology, University of Parakou, Parakou, Benin
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Tardelli LP, Duchatsch F, Herrera NA, Ruiz TFR, Pagan LU, Vicentini CA, Okoshi K, Amaral SL. Benefits of combined exercise training on arterial stiffness and blood pressure in spontaneously hypertensive rats treated or not with dexamethasone. Front Physiol 2022; 13:916179. [PMID: 36045742 PMCID: PMC9420846 DOI: 10.3389/fphys.2022.916179] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
Dexamethasone (DEX)-induced arterial stiffness is an important side-effect, associated with hypertension and future cardiovascular events, which can be counteracted by exercise training. The aim of this study was to evaluate the mechanisms induced by combined training to attenuate arterial stiffness and hypertension in spontaneously hypertensive rats treated or not with dexamethasone. Spontaneously hypertensive rats (SHR) underwent combined training for 74 days and were treated with dexamethasone (50 µg/kg s. c.) or saline solution during the last 14 days. Wistar rats were used as controls. Echocardiographic parameters, blood pressure (BP) and pulse wave velocity (PWV), as well as histological analyses of the heart and aorta, carotid and femoral arteries were performed. At the beginning, SHR had higher BP and PWV compared with Wistar rats. After 60 days, while BP increased in sedentary SHR, combined exercise training decreased BP and PWV. After 74d, the higher BP and PWV of sedentary SHR was accompanied by autonomic imbalance to the heart, cardiac remodeling, and higher arterial collagen deposition. DEX treatment did not change these parameters. On the other hand, trained SHR had reduced BP and PWV, which was associated with better autonomic balance to the heart, reduced myocardial collagen deposition, as well as lower arterial collagen deposition. The results of this study suggest that combined training, through the reduction of aortic collagen deposition, is an important strategy to reduce arterial stiffness in spontaneously hypertensive rats, and these lower responses were maintained regardless of dexamethasone treatment.
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Affiliation(s)
- Lidieli P. Tardelli
- Joint Graduate Program in Physiological Sciences, PIPGCF UFSCar/UNESP, São Carlos, SP, Brazil
- Department of Physical Education, São Paulo State University (UNESP), School of Sciences, Bauru, SP, Brazil
| | - Francine Duchatsch
- Joint Graduate Program in Physiological Sciences, PIPGCF UFSCar/UNESP, São Carlos, SP, Brazil
- Department of Physical Education, São Paulo State University (UNESP), School of Sciences, Bauru, SP, Brazil
| | - Naiara A. Herrera
- Joint Graduate Program in Physiological Sciences, PIPGCF UFSCar/UNESP, São Carlos, SP, Brazil
- Department of Physical Education, São Paulo State University (UNESP), School of Sciences, Bauru, SP, Brazil
| | - Thalles Fernando R. Ruiz
- Joint Graduate Program in Animal Biology, São Paulo State University (UNESP), São José do Rio Preto, SP, Brazil
| | - Luana U. Pagan
- Department of Internal Medicine, São Paulo State University (UNESP), Botucatu Medical School, Botucatu, SP, Brazil
| | - Carlos A. Vicentini
- Department of Biological Sciences, São Paulo State University (UNESP), School of Sciences, Bauru, SP, Brazil
| | - Katashi Okoshi
- Department of Internal Medicine, São Paulo State University (UNESP), Botucatu Medical School, Botucatu, SP, Brazil
| | - Sandra L. Amaral
- Joint Graduate Program in Physiological Sciences, PIPGCF UFSCar/UNESP, São Carlos, SP, Brazil
- Department of Physical Education, São Paulo State University (UNESP), School of Sciences, Bauru, SP, Brazil
- *Correspondence: Sandra L. Amaral,
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Marzolini S, Wu C, Hussein R, Xiong LY, Kangatharan S, Peni A, Cooper CR, Lau KS, Nzodjou Makhdoom G, Pakosh M, Zaban SA, Nguyen MM, Banihashemi MA, Swardfager W. Associations Between Time After Stroke and Exercise Training Outcomes: A Meta-Regression Analysis. J Am Heart Assoc 2021; 10:e022588. [PMID: 34913357 PMCID: PMC9075264 DOI: 10.1161/jaha.121.022588] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Knowledge gaps exist regarding the effect of time elapsed after stroke on the effectiveness of exercise training interventions, offering incomplete guidance to clinicians. Methods and Results To determine the associations between time after stroke and 6-minute walk distance, 10-meter walk time, cardiorespiratory fitness and balance (Berg Balance Scale score [BBS]) in exercise training interventions, relevant studies in post-stroke populations were identified by systematic review. Time after stroke as continuous or dichotomized (≤3 months versus >3 months, and ≤6 months versus >6 months) variables and weighted mean differences in postintervention outcomes were examined in meta-regression analyses adjusted for study baseline mean values (pre-post comparisons) or baseline mean values and baseline control-intervention differences (controlled comparisons). Secondary models were adjusted additionally for mean age, sex, and aerobic exercise intensity, dose, and modality. We included 148 studies. Earlier exercise training initiation was associated with larger pre-post differences in mobility; studies initiated ≤3 months versus >3 months after stroke were associated with larger differences (weighted mean differences [95% confidence interval]) in 6-minute walk distance (36.3 meters; 95% CI, 14.2-58.5), comfortable 10-meter walk time (0.13 m/s; 95% CI, 0.06-0.19) and fast 10-meter walk time (0.16 m/s; 95% CI, 0.03-0.3), in fully adjusted models. Initiation ≤3 months versus >3 months was not associated with cardiorespiratory fitness but was associated with a higher but not clinically important Berg Balance Scale score difference (2.9 points; 95% CI, 0.41-5.5). In exercise training versus control studies, initiation ≤3 months was associated with a greater difference in only postintervention 6-minute walk distance (baseline-adjusted 27.3 meters; 95% CI, 6.1-48.5; fully adjusted, 24.9 meters; 95% CI, 0.82-49.1; a similar association was seen for ≤6 months versus >6 months after stroke (fully adjusted, 26.6 meters; 95% CI, 2.6-50.6). Conclusions There may be a clinically meaningful benefit to mobility outcomes when exercise is initiated within 3 months and up to 6 months after stroke.
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Affiliation(s)
- Susan Marzolini
- KITE Research Institute, Toronto Rehabilitation Institute ‐ University Health NetworkTorontoONCanada
- Healthy Living for Pandemic Event Protection (HL–PIVOT) NetworkTorontoONCanada
- Rehabilitation Sciences InstituteUniversity of TorontoONCanada
- Faculty of Kinesiology and Physical EducationUniversity of TorontoONCanada
| | - Che‐Yuan Wu
- Department of Pharmacology and ToxicologyUniversity of TorontoONCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
| | | | - Lisa Y. Xiong
- Department of Pharmacology and ToxicologyUniversity of TorontoONCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
| | - Suban Kangatharan
- KITE Research Institute, Toronto Rehabilitation Institute ‐ University Health NetworkTorontoONCanada
| | - Ardit Peni
- KITE Research Institute, Toronto Rehabilitation Institute ‐ University Health NetworkTorontoONCanada
| | | | - Kylie S.K. Lau
- Department of Human BiologyUniversity of TorontoONCanada
| | | | - Maureen Pakosh
- Library & Information ServicesUniversity Health NetworkToronto Rehabilitation InstituteTorontoONCanada
| | - Stephanie A. Zaban
- Faculty of Kinesiology and Physical EducationUniversity of TorontoONCanada
| | - Michelle M. Nguyen
- Department of Pharmacology and ToxicologyUniversity of TorontoONCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
| | - Mohammad Amin Banihashemi
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
- Institute of Medical ScienceUniversity of TorontoTorontoONCanada
| | - Walter Swardfager
- KITE Research Institute, Toronto Rehabilitation Institute ‐ University Health NetworkTorontoONCanada
- Department of Pharmacology and ToxicologyUniversity of TorontoONCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
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Saz-Lara A, Cavero-Redondo I, Álvarez-Bueno C, Notario-Pacheco B, Reina-Gutiérrez S, Sequí-Domínguez I, Ruiz JR, Martínez-Vizcaíno V. What type of physical exercise should be recommended for improving arterial stiffness on adult population? A network meta-analysis. Eur J Cardiovasc Nurs 2021; 20:696-716. [PMID: 33837399 DOI: 10.1093/eurjcn/zvab022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/27/2021] [Accepted: 03/10/2021] [Indexed: 12/24/2022]
Abstract
AIMS Physical exercise has been associated with a reduction in arterial stiffness, a subclinical process underlying cardiovascular disease. However, the effect of different types of exercise (aerobic, resistance, combined, interval training, stretching, or mind-body modalities) on arterial stiffness is unclear. This network meta-analysis aimed to examine the effectiveness of different types of exercise on arterial stiffness as measured by pulse wave velocity in adults. METHODS AND RESULTS We searched Cochrane Central Register of Controlled Trials, CINAHL, MEDLINE (via Pubmed), Embase, and Web of Science databases, for randomized clinical trials including at least a comparison group, from their inception to 30 June 2020. A frequentist network meta-analysis was performed to compare the effect of different types of physical exercise on arterial stiffness as measured by pulse wave velocity. Finally, 35 studies, with a total of 1125 participants for exercise intervention and 633 participants for the control group, were included. In the pairwise meta-analyses, the exercises that improved arterial stiffness were: interval training [effect size (ES) 0.37; 95% confidence interval (CI) 0.01-0.73], aerobic exercise (ES 0.30; 95% CI 0.13-0.48) and combined exercise (ES 0.22; 95% CI 0.04-0.40). Furthermore, the network meta-analysis showed that mind-body interventions were the most effective type of exercise to reduce the pulse wave velocity (ES 0.86; 95% CI 0.04-1.69). In addition, combined exercise (ES 0.35; 95% CI 0.08-0.62), aerobic exercise (ES 0.33; 95% CI 0.09-0.57), and interval training (ES 0.33; 95% CI 0.02-0.64) showed significant improvements. CONCLUSION Our findings showed that aerobic exercise, combined exercise, interval training, and mind-body exercises were the most effective exercise modalities for reducing arterial stiffness, assuming an important role in the prevention of cardiovascular diseases.
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Affiliation(s)
- Alicia Saz-Lara
- Universidad de Castilla-La Mancha, Health and Social Research Center, Santa Teresa Jornet s/n, 16171 Cuenca, Spain
| | - Iván Cavero-Redondo
- Universidad de Castilla-La Mancha, Health and Social Research Center, Santa Teresa Jornet s/n, 16171 Cuenca, Spain.,Rehabilitation in Health Research Center (CIRES), Universidad de las Americas, Av. República 71, Santiago, Chile
| | - Celia Álvarez-Bueno
- Universidad de Castilla-La Mancha, Health and Social Research Center, Santa Teresa Jornet s/n, 16171 Cuenca, Spain.,Universidad Politécnica y Artística del Paraguay, Mayor Sebastián Bullo, 001518 Asunción, Paraguay
| | - Blanca Notario-Pacheco
- Universidad de Castilla-La Mancha, Health and Social Research Center, Santa Teresa Jornet s/n, 16171 Cuenca, Spain
| | - Sara Reina-Gutiérrez
- Universidad de Castilla-La Mancha, Health and Social Research Center, Santa Teresa Jornet s/n, 16171 Cuenca, Spain
| | - Irene Sequí-Domínguez
- Universidad de Castilla-La Mancha, Health and Social Research Center, Santa Teresa Jornet s/n, 16171 Cuenca, Spain
| | - Jonatan R Ruiz
- PROmoting FITness and Health through physical activity Research Group (PROFITH), Department of Physical Activity and Sports Education, Sport and Health, University Research Institute (iMUDS), Faculty of Sports Science, University of Granada, Crta Alfacar s/n. 18011 Granada, Spain
| | - Vicente Martínez-Vizcaíno
- Universidad de Castilla-La Mancha, Health and Social Research Center, Santa Teresa Jornet s/n, 16171 Cuenca, Spain.,Universidad Autónoma de Chile, Facultad de Ciencias de la Salud, Av. Pedro de Valdivia 425, Talca, Chile
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Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury. J Neurol Phys Ther 2021; 44:49-100. [PMID: 31834165 DOI: 10.1097/npt.0000000000000303] [Citation(s) in RCA: 156] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses. METHODS A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit. RESULTS Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality-based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality-based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight-supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. DISCUSSION The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient's engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy. LIMITATIONS As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance. SUMMARY The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury. DISCLAIMER These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.
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Saunders DH, Sanderson M, Hayes S, Johnson L, Kramer S, Carter DD, Jarvis H, Brazzelli M, Mead GE. Physical fitness training for stroke patients. Cochrane Database Syst Rev 2020; 3:CD003316. [PMID: 32196635 PMCID: PMC7083515 DOI: 10.1002/14651858.cd003316.pub7] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- David H Saunders
- University of EdinburghPhysical Activity for Health Research Centre (PAHRC)St Leonards LandHolyrood RoadEdinburghMidlothianUKEH8 8AQ
| | - Mark Sanderson
- University of the West of ScotlandInstitute of Clinical Exercise and Health ScienceRoom A071A, Almada BuildingHamiltonUKML3 0JB
| | - Sara Hayes
- University of LimerickSchool of Allied Health, Ageing Research Centre, Health Research InstituteLimerickIreland
| | - Liam Johnson
- University of MelbourneThe Florey Institute of Neuroscience and Mental HealthHeidelbergAustralia3084
| | - Sharon Kramer
- University of MelbourneThe Florey Institute of Neuroscience and Mental HealthHeidelbergAustralia3084
| | - Daniel D Carter
- University of LimerickSchool of Allied Health, Faculty of Education and Health SciencesLimerickIreland
| | - Hannah Jarvis
- Manchester Metropolitan UniversityResearch Centre for Musculoskeletal Science and Sports Medicine, Faculty of Science and EngineeringJohn Dalton BuildingChester StreetManchesterUKM1 5GD
| | - Miriam Brazzelli
- University of AberdeenHealth Services Research UnitHealth Sciences BuildingForesterhillAberdeenUKAB25 2ZD
| | - Gillian E Mead
- University of EdinburghCentre for Clinical Brain SciencesRoom S1642, Royal InfirmaryLittle France CrescentEdinburghUKEH16 4SA
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Lee J, Stone AJ. Combined Aerobic and Resistance Training for Cardiorespiratory Fitness, Muscle Strength, and Walking Capacity after Stroke: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2019; 29:104498. [PMID: 31732460 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104498] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/11/2019] [Accepted: 10/23/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Cardiorespiratory fitness, measured as peak oxygen consumption, is a potent predictor of stroke risk. Muscle weakness is the most prominent impairment after stroke and is directly associated with reduced walking capacity. There is a lack of recommendations for optimal combined aerobic training and resistance training for those patients. The purpose of this study was to systematically review and quantify the effects of exercise training on cardiorespiratory fitness, muscle strength, and walking capacity after stroke. METHODS Five electronic databases were searched (until May 2019) for studies that met the following criteria: (1) adult humans with a history of stroke who ambulate independently; (2) structured exercise intervention based on combined aerobic training and resistance training; and (3) measured cardiorespiratory fitness, muscle strength, and/or walking capacity. RESULTS Eighteen studies (602 participants, average age 62 years) met the inclusion criteria. Exercise training significantly improved all 3 outcomes. In subgroup analyses for cardiorespiratory fitness, longer training duration was significantly associated with larger effect size. Likewise, for muscle strength, moderate weekly frequency and lower training volume were significantly associated with larger effect size. Furthermore, in walking capacity, moderate weekly frequency and longer training duration were significantly associated with larger effect size. CONCLUSIONS These results suggest that an exercise program consisting of moderate-intensity, 3 days per week, for 20 weeks should be considered for greater effect on cardiorespiratory fitness, muscle strength, and walking capacity in stroke patients.
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Affiliation(s)
- Junghoon Lee
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, Texas
| | - Audrey J Stone
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, Texas.
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Pogrebnoy D, Dennett A. Exercise Programs Delivered According to Guidelines Improve Mobility in People With Stroke: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil 2019; 101:154-165. [PMID: 31400308 DOI: 10.1016/j.apmr.2019.06.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/20/2019] [Accepted: 06/26/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine if prescribing a combined aerobic and resistance training exercise program in accordance with American Stroke Association physical activity guidelines improves mobility and physical activity levels of people after stroke. DATA SOURCES Online database search from earliest available date to August 27, 2018. STUDY SELECTION Randomized controlled trials evaluating the effectiveness of exercise programs prescribed in accordance with guidelines for improving mobility and physical activity levels in adults with subacute or chronic stroke. DATA EXTRACTION Two independent reviewers completed data extraction. Risk of bias was assessed using the Physiotherapy Evidence Database Scale, and overall quality of evidence was assessed using the Grades of Research, Assessment, Development, and Evaluation approach. DATA SYNTHESIS Data was pooled from a total of 499 participants for meta-analysis. There was high-level evidence that exercise programs adhering to guidelines improve habitual walking speed (mean difference, 0.07m/s; 95% CI, -0.01 to 0.16) and walking endurance (mean difference, 39.2m, 95% CI, 17.2-61.2). A sensitivity analysis demonstrated high-level evidence of improvements in walking endurance (mean difference, 51.1m; 95% CI, 19.96-82.24) and moderate-level evidence of improvements on the Timed Up and Go test (standardized mean difference, 0.57; 95% CI, 0.16-0.99). No differences were detected for other mobility outcome measures or physical activity levels. Adherence was high and few adverse events were reported. CONCLUSION A combined exercise program comprising aerobic and resistance training that adheres to the American Stroke Association guidelines is safe and should be prescribed in addition to usual care to improve mobility. Further research is needed to understand the relationship between exercise programs and behavior change requirements to improve long-term physical activity levels.
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Affiliation(s)
- Dina Pogrebnoy
- Community Rehabilitation Program, Eastern Health, Victoria, Australia.
| | - Amy Dennett
- Allied Health Clinical Research Office, Eastern Health, Victoria, Australia
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Effects of Resistance Training on Arterial Stiffness in Persons at Risk for Cardiovascular Disease: A Meta-analysis. Sports Med 2018; 48:2785-2795. [DOI: 10.1007/s40279-018-1001-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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12
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Zhang Y, Qi L, Xu L, Sun X, Liu W, Zhou S, van de Vosse F, Greenwald SE. Effects of exercise modalities on central hemodynamics, arterial stiffness and cardiac function in cardiovascular disease: Systematic review and meta-analysis of randomized controlled trials. PLoS One 2018; 13:e0200829. [PMID: 30036390 PMCID: PMC6056055 DOI: 10.1371/journal.pone.0200829] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 06/29/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Exercise is accepted as an important contribution to the rehabilitation of patients with cardiovascular disease (CVD). This study aims to better understand the possible causes for lack of consensus and reviews the effects of three exercise modalities (aerobic, resistance and combined exercise) on central hemodynamics, arterial stiffness and cardiac function for better rehabilitation strategies in CVD. METHODS The electronic data sources, Cochrane Library, MEDLINE, Web of Science, EBSCO (CINAHL), and ScienceDirect from inception to July 2017 were searched for randomized controlled trials (RCTs) investigating the effect of exercise modalities in adult patients with CVD. The effect size was estimated as mean differences (MD) with 95% confidence intervals (CI). Subgroup analysis and meta-regression were used to study potential moderating factors. RESULTS Thirty-eight articles describing RCTs with a total of 2089 patients with CVD were included. The pooling revealed that aerobic exercise [MD(95%CI) = -5.87 (-8.85, -2.88), P = 0.0001] and resistance exercise [MD(95%CI) = -7.62 (-10.69, -4.54), P<0.00001] significantly decreased aortic systolic pressure (ASP). Resistance exercise significantly decreased aortic diastolic pressure [MD(95%CI) = -4(-5.63, -2.37), P<0.00001]. Aerobic exercise significantly decreased augmentation index (AIx) based on 24-week exercise duration and patients aged 50-60 years. Meanwhile, aerobic exercise significantly improved carotid-femoral pulse wave velocity (cf-PWV) [MD(95%CI) = -0.42 (-0.83, -0.01), P = 0.04], cardiac output (CO) [MD(95% CI) = 0.36(0.08, 0.64), P = 0.01] and left ventricular ejection fraction (LVEF) [MD(95%CI) = 3.02 (2.11, 3.93), P<0.00001]. Combined exercise significantly improved cf-PWV [MD(95%CI) = -1.15 (-1.95, -0.36), P = 0.004] and CO [MD(95% CI) = 0.9 (0.39, 1.41), P = 0.0006]. CONCLUSIONS Aerobic and resistance exercise significantly decreased ASP, and long-term aerobic exercise reduced AIx. Meanwhile, aerobic and combined exercise significantly improved central arterial stiffness and cardiac function in patients with CVD. These findings suggest that a well-planned regime could optimize the beneficial effects of exercise and can provide some evidence-based guidance for those involved in cardiovascular rehabilitation of patients with CVD.
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Affiliation(s)
- Yahui Zhang
- Sino-Dutch Biomedical and Information Engineering School, Northeastern University, Shenyang, Liaoning, China
| | - Lin Qi
- Sino-Dutch Biomedical and Information Engineering School, Northeastern University, Shenyang, Liaoning, China
| | - Lisheng Xu
- Sino-Dutch Biomedical and Information Engineering School, Northeastern University, Shenyang, Liaoning, China
- Key Laboratory of Medical Image Computing, Ministry of Education, Northeastern University, Shenyang, Liaoning, China
| | - Xingguo Sun
- Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Beijing, China
| | - Wenyan Liu
- Sino-Dutch Biomedical and Information Engineering School, Northeastern University, Shenyang, Liaoning, China
| | - Shuran Zhou
- Sino-Dutch Biomedical and Information Engineering School, Northeastern University, Shenyang, Liaoning, China
| | - Frans van de Vosse
- Sino-Dutch Biomedical and Information Engineering School, Northeastern University, Shenyang, Liaoning, China
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Stephen E. Greenwald
- Blizard Institute, Barts & The London School of Medicine &Dentistry, Queen Mary University of London, London, United Kingdom
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13
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Wang C, Redgrave J, Shafizadeh M, Majid A, Kilner K, Ali AN. Aerobic exercise interventions reduce blood pressure in patients after stroke or transient ischaemic attack: a systematic review and meta-analysis. Br J Sports Med 2018; 53:1515-1525. [PMID: 29743171 DOI: 10.1136/bjsports-2017-098903] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Secondary vascular risk reduction is critical to preventing recurrent stroke. We aimed to evaluate the effect of exercise interventions on vascular risk factors and recurrent ischaemic events after stroke or transient ischaemic attack (TIA). DESIGN Intervention systematic review and meta-analysis. DATA SOURCES OVID MEDLINE, PubMed, The Cochrane Library, Web of Science, The National Institute for Health and Care Excellence, TRIP Database, CINAHL, PsycINFO, SCOPUS, UK Clinical Trials Gateway and the China National Knowledge Infrastructure were searched from 1966 to October 2017. ELIGIBILITY CRITERIA Randomised controlled trials evaluating aerobic or resistance exercise interventions on vascular risk factors and recurrent ischaemic events among patients with stroke or TIA, compared with control. RESULTS Twenty studies (n=1031) were included. Exercise interventions resulted in significant reductions in systolic blood pressure (SBP) -4.30 mm Hg (95% CI -6.77 to -1.83) and diastolic blood pressure -2.58 mm Hg (95% CI -4.7 to -0.46) compared with control. Reduction in SBP was most pronounced among studies initiating exercise within 6 months of stroke or TIA (-8.46 mm Hg, 95% CI -12.18 to -4.75 vs -2.33 mm Hg, 95% CI -3.94 to -0.72), and in those incorporating an educational component (-7.81 mm Hg, 95% CI -14.34 to -1.28 vs -2.78 mm Hg, 95% CI -4.33 to -1.23). Exercise was also associated with reductions in total cholesterol (-0.27 mmol/L, 95% CI -0.54 to 0.00), but not fasting glucose or body mass index. One trial reported reductions in secondary vascular events with exercise, but was insufficiently powered. SUMMARY Exercise interventions can result in clinically meaningful blood pressure reductions, particularly if initiated early and alongside education.
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Affiliation(s)
- Cheng Wang
- Faculty of Medicine Dentistry and Health, University of Sheffield, Sheffield, UK
| | - Jessica Redgrave
- Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Mohsen Shafizadeh
- Sheffield Hallam University, Academy of Sport and Physical Activity, Sheffield, UK
| | - Arshad Majid
- Faculty of Medicine Dentistry and Health, University of Sheffield, Sheffield, UK.,Sheffield NIHR Biomedical Research Centre, Sheffield, UK
| | - Karen Kilner
- Sheffield Hallam University, Centre for Health and Social Care Research, Sheffield, UK
| | - Ali N Ali
- Faculty of Medicine Dentistry and Health, University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Geriatrics and Stroke Medicine, Sheffield, UK
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Do Trials of Resistance Training to Improve Mobility After Stroke Adhere to the American College of Sports Medicine Guidelines? A Systematic Review. Arch Phys Med Rehabil 2018; 99:584-597.e13. [DOI: 10.1016/j.apmr.2017.06.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 05/17/2017] [Accepted: 06/15/2017] [Indexed: 11/17/2022]
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Current Trends in Exercise Intervention Research, Technology, and Behavioral Change Strategies for People With Disabilities. Am J Phys Med Rehabil 2017; 96:748-761. [DOI: 10.1097/phm.0000000000000743] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Abstract
BACKGROUND Circuit class therapy (CCT) offers a supervised group forum for people after stroke to practise tasks, enabling increased practice time without increasing staffing. This is an update of the original review published in 2010. OBJECTIVES To examine the effectiveness and safety of CCT on mobility in adults with stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched January 2017), CENTRAL (the Cochrane Library, Issue 12, 2016), MEDLINE (1950 to January 2017), Embase (1980 to January 2017), CINAHL (1982 to January 2017), and 14 other electronic databases (to January 2017). We also searched proceedings from relevant conferences, reference lists, and unpublished theses; contacted authors of published trials and other experts in the field; and searched relevant clinical trials and research registers. SELECTION CRITERIA Randomised controlled trials (RCTs) including people over 18 years old, diagnosed with stroke of any severity, at any stage, or in any setting, receiving CCT. DATA COLLECTION AND ANALYSIS Review authors independently selected trials for inclusion, assessed risk of bias in all included studies, and extracted data. MAIN RESULTS We included 17 RCTs involving 1297 participants. Participants were stroke survivors living in the community or receiving inpatient rehabilitation. Most could walk 10 metres without assistance. Ten studies (835 participants) measured walking capacity (measuring how far the participant could walk in six minutes) demonstrating that CCT was superior to the comparison intervention (Six-Minute Walk Test: mean difference (MD), fixed-effect, 60.86 m, 95% confidence interval (CI) 44.55 to 77.17, GRADE: moderate). Eight studies (744 participants) measured gait speed, again finding in favour of CCT compared with other interventions (MD 0.15 m/s, 95% CI 0.10 to 0.19, GRADE: moderate). Both of these effects are considered clinically meaningful. We were able to pool other measures to demonstrate the superior effects of CCT for aspects of walking and balance (Timed Up and Go: five studies, 488 participants, MD -3.62 seconds, 95% CI -6.09 to -1.16; Activities of Balance Confidence scale: two studies, 103 participants, MD 7.76, 95% CI 0.66 to 14.87). Two other pooled balance measures failed to demonstrate superior effects (Berg Blance Scale and Step Test). Independent mobility, as measured by the Stroke Impact Scale, Functional Ambulation Classification and the Rivermead Mobility Index, also improved more in CCT interventions compared with others. Length of stay showed a non-significant effect in favour of CCT (two trials, 217 participants, MD -16.35, 95% CI -37.69 to 4.99). Eight trials (815 participants) measured adverse events (falls during therapy): there was a non-significant effect of greater risk of falls in the CCT groups (RD 0.03, 95% CI -0.02 to 0.08, GRADE: very low). Time after stroke did not make a difference to the positive outcomes, nor did the quality or size of the trials. Heterogeneity was generally low; risk of bias was variable across the studies with poor reporting of study conduct in several of the trials. AUTHORS' CONCLUSIONS There is moderate evidence that CCT is effective in improving mobility for people after stroke - they may be able to walk further, faster, with more independence and confidence in their balance. The effects may be greater later after the stroke, and are of clinical significance. Further high-quality research is required, investigating quality of life, participation and cost-benefits, that compares CCT with standard care and that also investigates the influence of factors such as stroke severity and age. The potential risk of increased falls during CCT needs to be monitored.
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Affiliation(s)
- Coralie English
- University of NewcastleSchool of Health Sciences and Priority Research Centre for Stroke and Brain InjuryUniversity DrCallaghanNSWAustralia2308
- NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Florey Institute of Neuroscience and Mental Health & Hunter Medical Research InstituteMelbourne and NewcastleAustralia
| | - Susan L Hillier
- University of South Australia (City East)Sansom Institute for Health ResearchNorth TerraceAdelaideSAAustralia5000
| | - Elizabeth A Lynch
- NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Florey Institute of Neuroscience and Mental Health & Hunter Medical Research InstituteMelbourne and NewcastleAustralia
- The University of AdelaideAdelaide Nursing SchoolAdelaideSouth AustraliaAustralia
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