Fitness and Mobility Exercise (FAME) Program for stroke

Evaluating the Educational Experience of Physiotherapy Students Using the Fitness and Mobility Exercise (FAME) Programme to Learn about Neurological Conditions: An Exploratory Study

Purpose

Group exercise has the potential to be a cost-effective way to improve functional outcomes for those living with neurological injury. Leading group exercise is a foundational competency for entry-to-practice for physiotherapy students. The overall objective of this study was to examine the student experience of using the Fitness and Mobility Exercise (FAME) programme to learn about neurological conditions in a group setting.

Methods

Sixteen physiotherapy students filled out a single point in time survey at the end of their placement during which they had the opportunity to use FAME with their clients twice a week. The survey had Likert and open-ended questions and demographic information. Likert responses were calculated as means. Open-ended questions were analyzed using thematic analysis.

Results

The Likert questions were answered with almost entirely positive results. The main themes from the open-ended questions were how to personalize the class, characteristics of individual clients shape the class experience and factors that make the class successful.

Conclusions

Overall, the physiotherapy students found using FAME to be a positive experience. From the student perspective, using FAME during placement was an effective way to learn about neurological conditions as well as to develop skills to manage a group exercise class.

An 8-week Forced-rate Aerobic Cycling Program Improves Cardiorespiratory Fitness in Persons With Chronic Stroke: A Randomized Controlled Trial

OBJECTIVE

To examine the cardiorespiratory effects of a forced-rate aerobic exercise (FE) intervention among individuals with chronic stroke compared with an upper extremity repetitive task practice (UE RTP) control group.

DESIGN

Secondary analysis of data from a randomized controlled trial.

SETTING

Research laboratory.

PARTICIPANTS

Individuals with chronic stroke (N=60).

INTERVENTIONS

Participants completed 24 sessions of FE followed by RTP (FE+RTP, N=30) or time matched RTP alone (N=30). The FE+RTP group was prescribed exercise at 60%-80% of heart rate reserve on a motorized stationary cycle ergometer for 45 minutes followed by 45 minutes of RTP. The control group completed 90 minutes of RTP.

MAIN OUTCOME MEASURES

Metabolic exercise stress tests on a cycle ergometer were conducted at baseline and post-intervention. Outcomes included peak oxygen consumption (peak V̇o2) and anaerobic threshold (AT).

RESULTS

Fifty participants completed the study intervention and pre/post stress tests. The FE+RTP group demonstrated significantly greater improvements in peak V̇o2 from 16.4±5.7 to 18.3±6.4 mL/min/kg compared with the RTP group (17.0±5.6 to 17.2±5.6 mL/min/kg, P=.020) and significantly greater improvements in AT from 10.3±2.8 to 11.5±3.6 mL/min/kg compared with the RTP group (10.8±3.9 to 10.4±3.2 mL/min/kg, P=.020). In analyzing predictors of post-intervention peak V̇o2, the multivariable linear regression model did not reveal a significant effect of age, sex, body mass index, or beta blocker usage. Similarly, bivariate linear regression models for the FE group only did not find any exercise variables (aerobic intensity, power, or cycling cadence) to be significant predictors of peak V̇o2.

CONCLUSIONS

While the aerobic exercise intervention was integrated into rehabilitation to improve UE motor recovery, it was also effective in eliciting significant and meaningful improvements in cardiorespiratory fitness. This novel rehabilitation model may be an effective approach to improve motor and cardiorespiratory function in persons recovering from stroke.

A Community Needs Assessment and Implementation Planning for a Community Exercise Program for Survivors of Stroke: Protocol for a Pilot Hybrid Type I Clinical Effectiveness and Implementation Study

BACKGROUND

Physical activity and exercise are important aspects of maintaining health. People with mobility impairments, including survivors of stroke, are less likely to exercise and at greater risk of developing or worsening chronic health conditions. Increasing accessible, desired options for exercise may address the gap in available physical activity programs, provide an opportunity for continued services after rehabilitation, and cultivate social connections for people after stroke and others with mobility impairments. Existing evidence-based community programs for people after stroke target cardiovascular endurance, mobility, walking ability, balance, and education. While much is known about the effectiveness of these programs, it is important to understand the local environment as implementation and sustainment strategies are context-specific.

OBJECTIVE

This study protocol aims to evaluate community needs and resources for exercise for adults living with mobility impairments with initial emphasis on survivors of stroke in Richland County, South Carolina. Results will inform a hybrid type I effectiveness and implementation pilot of an evidence-based group exercise program for survivors of stroke.

METHODS

The exploration and preparation phases of the EPIS (Exploration, Preparation, Implementation, and Sustainment) implementation model guide the study. A community needs assessment will evaluate the needs and desires of survivors of stroke through qualitative semistructured interviews with survivors of stroke, rehabilitation professionals, and fitness trainers serving people with mobility impairments. Additional data will be collected from survivors of stroke through a survey. Fitness center sites will be assessed through interviews and the Accessibility Instrument Measuring Fitness and Recreation Environments inventory. Qualitative data will be evaluated using content analysis and supported by mean survey results. Data will be categorized by the community (outer context), potential participants (outer context), and fitness center (inner context) and evaluate needs, resources, barriers, and facilitators. Results will inform evidence-based exercise program selection, adaptations, and specific local implementation strategies to influence success. Pilot outcome measures for participants (clinical effectiveness), process, and program delivery levels will be identified. An implementation logic model for interventions will be created to reflect the design elements for the pilot and their complex interactions.

RESULTS

The study was reviewed by the institutional review board and exempt approved on December 19, 2023. The study data collection began in January 2024 and is projected to be completed in June 2024. A total of 17 participants have been interviewed as of manuscript submission. Results are expected to be published in early 2025.

CONCLUSIONS

Performing a needs assessment before implementing it in the community allows for early identification of complex relationships and preplanning to address problems that cannot be anticipated in controlled effectiveness research. Evaluation and preparation prior to implementation of a community exercise program enhance the potential to be successful, valued, and sustained in the community.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55432.

Investigating the Telerehabilitation With Aims to Improve Lower Extremity Recovery Poststroke Program: A Feasibility Study

OBJECTIVE

The purpose of this study was to examine the feasibility of a progressive virtual exercise and self-management intervention, the TeleRehabilitation with Aims to Improve Lower extremity recovery poststroke program (TRAIL), in individuals with stroke.

METHODS

A single group pre-post study design was used. Thirty-two participants were recruited who were aged 19 years or older, had a stroke within 18 months of the beginning of the study, had hemiparesis of the lower extremity, and were able to tolerate 50 minutes of activity. Participants completed TRAIL, a synchronous exercise and self-management program delivered via videoconferencing. Participants received 8 telerehabilitation sessions over 4 weeks that were 60 to 90 minutes, with a trained physical therapist in a ≤2 to 1 participant-to-therapist ratio. Feasibility indicators in the areas of process (recruitment and retention rates, perceived satisfaction), resources (treatment fidelity and adherence, participant and assessor burden, therapist burden), management (equipment, processing time), and scientific indicators (safety, treatment response, treatment effect) were collected throughout the study using a priori criteria for success. The treatment effect was examined on the Timed "Up & Go" test, the virtual Fugl-Meyer Lower Extremity Assessment, the 30-Second Sit-to-Stand Test, the Functional Reach, the Tandem Stand, the Activities-Specific Balance Confidence Scale, the Stroke Impact Scale, and the Goal Attainment Scale.

RESULTS

Forty-seven individuals were screened, of which 32 (78% male; median age of 64.5 years) were included for the study from 5 sites across Canada. Nine feasibility indicators met our study-specific threshold criteria for success: retention rate (0 dropouts), perceived satisfaction, treatment fidelity, adherence, therapist burden, equipment, and safety. In terms of treatment response and effect, improvements were observed in Timed "Up & Go" test (Cohen d = 0.57); Fugl-Meyer Lower Extremity Assessment (d = 0.76); 30-Second Sit-to-Stand Test (d = 0.89); and Goal Attainment Scale (d = 0.95).

CONCLUSION

The delivery of TRAIL, a lower extremity stroke rehabilitation program using videoconferencing technology, is feasible and appears to have positive influences on mobility, lower extremity impairment, strength, and goal attainment.

IMPACT

Community-based telerehabilitation programs, such as TRAIL, could extend the continuum of care during the transition back to community postdischarge or during global disruptions, such as Coronavirus Disease 2019 (COVID-19). Delivery of synchronous lower extremity rehabilitation via videoconferencing to community-dwelling stroke survivors is feasible.

Effect of exercise on functional capacity and body weight for people with hypertension, type 2 diabetes, or cardiovascular disease: a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Hypertension, type 2 diabetes, and cardiovascular disease affect the activities of daily living at varying degree. While the effects of aerobic exercise on functional capacity are well-documented, the extent of change for different types of exercise in these chronic conditions remains unexplored. Additionally, there is conflicting evidence regarding the role of exercise in reducing body weight.

METHODS

We conducted systematic review with meta-analysis and trial sequential analysis and searched various databases from inception to July 2020. We included randomised clinical trials adding any form of trialist defined exercise to usual care versus usual care in people with either hypertension, type 2 diabetes, and/or cardiovascular disease irrespective of setting, publication status, year, and language. The outcomes assessed were i) functional capacity assessed through different scales separately i.e., Maximal Oxygen Uptake (VO2max), 6-min walk test (6MWT), 10-m walk test (10MWT), and ii) body weight.

RESULTS

We included 950 studies out of which 444 trials randomising 20,098 participants reported on various functional outcomes (355 trials) and body weight (169 trials). The median follow-up was 3 months (Interquartile ranges (IQR): 2.25 to 6). Exercise added to the usual care, improved VO2max (Mean Difference (MD):2.72 ml/kg/min; 95% Confidence Interval (CI) 2.38 to 3.06; p < 0.01; I2 = 96%), 6MWT (MD: 42.5 m; 95%CI 34.95 to 50.06; p < 0.01; I2 = 96%), and 10MWT (MD: 0.06 m/s; 95%CI 0.03 to 0.10; p < 0.01; I2 = 93%). Dynamic aerobic and resistance exercise showed a consistent improvement across various functional outcomes, whereas body-mind therapies (MD: 3.23 ml/kg/min; 95%CI 1.97 to 4.49, p < 0.01) seemed especially beneficial for VO2max and inspiratory muscle training (MD: 59.32 m; 95%CI 33.84 to 84.80; p < 0.01) for 6MWT. Exercise yielded significant reduction in body weight for people with hypertension (MD: -1.45 kg; 95%CI -2.47 to -0.43; p < 0.01), and type 2 diabetes (MD: -1.53 kg; 95%CI -2.19 to -0.87; p < 0.01) but not for cardiovascular disease with most pronounced for combined exercise (MD: -1.73 kg; 95%CI -3.08 to -0.39; p < 0.05). The very low certainty of evidence warrants cautious interpretations of the results.

CONCLUSION

Exercise seemed to improve functional capacity for people with hypertension, type 2 diabetes, and/or cardiovascular disease but the effectiveness seems to vary with different forms of exercise. The potentially superior improvement in VO2max and 6MWT by body-mind therapies and inspiratory muscle training calls for further exploration. Additionally, prescribing exercise for the sole purpose of losing weight may be a potential strategy for people with hypertension and type 2 diabetes. The extent of improvement in functional capacity and body weight reduction differed with different exercise regimens hence personalised exercise prescriptions tailored to individual needs may be of importance. PROSPERO REGISTRATION: PROSPERO registration number: CRD42019142313.

Group-based circuit training to improve mobility after stroke: a cross-sectional survey of German and Austrian physical therapists in outpatient settings

BACKGROUND

A contextual transferability analysis identified group-based circuit training (GCT) as an optimal intervention in German and Austrian outpatient physical therapy to improve mobility post-stroke. GCT incorporates task-oriented, high-repetitive, balance, aerobic and strength training and allows for increased therapy time without increasing personnel.

OBJECTIVE

To determine the extent to which German and Austrian physical therapists (PTs) use GCT and its components in the outpatient treatment of stroke-related mobility deficits and to identify factors associated with using GCT components.

METHODS

A cross-sectional online survey was conducted. Data were analyzed descriptively and using ordinal regression.

RESULTS

Ninety-three PTs participated. None reported using GCT moderately to frequently (4- 10/10 patients). The percentage of PTs reporting frequent use (7- 10/10 patients) of task-oriented, balance, strength, aerobic, and high-repetitive training was 45.2%, 43.0%, 26.9%, 19.4%, and 8.6%, respectively. Teaching or supervising students, time for evidence-based practice activities at work, and working in Austria was associated with using GCT components frequently.

CONCLUSION

German and Austrian PTs do not yet use GCT in outpatient physical therapy for stroke. Almost half of PTs, however, employ task-oriented training as recommended across guidelines. A detailed, theory-driven and country-specific evaluation of barriers to GCT uptake is necessary to inform implementation.

Metaverse for Exercise Rehabilitation: Possibilities and Limitations

OBJECTIVES

This study aimed to obtain a consensus agreement from an expert panel on the metaverse for exercise rehabilitation in stroke patients using the Delphi technique.

METHODS

This study recruited twenty-two experts and conducted three rounds of online surveys between January and February 2023. The Delphi consensus technique was performed online to review and evaluate the framework module. A panel of experts, including scholars, physicians, physical therapists, and physical education specialists in the Republic of Korea, was invited to participate in this study. For each round, the expert consensus was defined as more than 90% of the expert panel agreeing or strongly agreeing with the proposed items.

RESULTS

A total of twenty experts completed the three Delphi rounds. First, virtual reality-assisted (VR) treadmill walking could improve cognitive function, concentration, muscular endurance, stroke prevention, proper weight maintenance, and cardiorespiratory function. Second, related technology, safety, price, place, and securing experts would be obstacles or challenges in VR-assisted treadmill walking for stroke patients. Third, the role of exercise instructors in exercise planning, performance, and assessment for VR-assisted treadmill walking is equally important, and reeducation for them is required. Fourth, VR-assisted treadmill walking for stroke patients requires an exercise intensity of at least five times a week, about one hour each time.

CONCLUSIONS

This study showed that the metaverse for exercise rehabilitation for stroke patients could be successfully developed and would be feasible to be implemented in the future. However, it would have limitations in terms of technology, safety, price, place, and expert factors to be overcome in the future.

Feasibility of a remotely supervised home-based group eHealth Fitness and Mobility Exercise program for stroke: French-Canadian version preliminary study

BACKGROUND

The numerous barriers to community-based physical activity programs have been exacerbated by the COVID-19 pandemic, especially among individuals with disabilities. eHealth programs may provide an alternative approach to address the physical activity needs of stroke survivors, but little is known about their feasibility or acceptance.

OBJECTIVE

The aims of this study were to 1) evaluate the feasibility of a remotely supervised home-based group eHealth program called Fitness and Mobility Exercise (FAME@home); 2) explore the influence of FAME@home on physical condition, mobility, self-efficacy, depression and anxiety; and 3) describe participants' satisfaction and experiences.

METHODS

A pre-post pilot study was used to recruit stroke survivors (>1 y post stroke) to complete a 12-week (2 days/week) eHealth program in small groups (n = 3). Feasibility indicators were assessed for process (e.g. inclusion criteria), resources (e.g. ability to use technology), management (e.g. major challenges), and treatment (e.g. influence on clinical outcomes and adverse events).

RESULTS

Nine participants were recruited with a mean (SD) of 60 (13) years of age and 7 (4) years post-stroke; eight completed the program. FAME@home was feasible for indicators of process, management, and treatment. Minor considerations to improve resources were suggested (i.e. support for technology use). There were statistically significant improvements in mobility after completion of FAME@home and 100% of the participants reported satisfaction. No adverse events occurred.

CONCLUSION

FAME@home was feasible to deliver as a remotely supervised group exercise program to community-dwelling stroke survivors, with high levels of retention and adherence. FAME@home improved accessibility to exercise and facilitated engagement by having a class schedule and social interaction.

Multimodal Agility-Based Exercise Training for Persons With Multiple Sclerosis: A New Framework

INTRODUCTION

Multimodal agility-based exercise training (MAT) has been described as a framework for fall prevention in the elderly but might also be a valuable concept for exercise training in persons with Multiple Sclerosis (pwMS).

THE PROBLEM

Current recommendations advise pwMS to perform a multitude of different exercise training activities, as each of these has its separate evidence. However, pwMS struggle even more than the general population to be physically active. Additionally, Multiple Sclerosis often leads to co-occurring mobility and cognitive dysfunctions, for which simultaneous, time-efficient, and engaging training approaches are still limited in clinical practice and healthcare.

THE SOLUTION

The MAT framework has been developed to integratively improve cardiovascular, neuromuscular, and cognitive function by combining aspects of perception and orientation, change of direction, as well as stop-and-go patterns (ie, agility), in a group-training format. For pwMS, the MAT framework is conceptualized to include 3 Components: standing balance, dynamic balance (including functional leg strength), and agility-based exercises. Within these Components sensory, cognitive, and cardiovascular challenges can be adapted to individual needs.

RECOMMENDATIONS

We recommend investigating multimodal exercise interventions that go beyond easily standardized, unimodal types of exercise (eg, aerobic or resistance exercise), which could allow for time-efficient training, targeting multiple frequent symptoms of persons with mild disability at once. MAT should be compared to unimodal approaches, regarding sensor-based gait outcomes, fatigue-related outcomes, cognition, as well as neuroprotective, and (supportive) disease-modifying effects.

Evaluating and Characterizing an Individually-Tailored Community Exercise Program for Older Adults With Chronic Neurological Conditions: A Mixed-Methods Study

A mixed-methods approach was used to study an individually-tailored community exercise program for people with a range of chronic neurological conditions (e.g., stroke, spinal cord injury, brain injury, multiple sclerosis, Parkinson's disease) and abilities. The program was delivered to older adults (mean age: 62 ± 9 years) with chronic neurological conditions across a 12-week and an 8-week term. Participants attended 88% of sessions and completed 89% of prescribed exercises in those sessions. There were no adverse events. Clinically important improvements were achieved by all evaluated participants (n = 8) in at least one testing domain (grip strength, lower-extremity strength, aerobic endurance, and balance). Interviews with participants identified key program elements as support through supervision, social connection, individualized programming, and experiential learning. Findings provide insight into elements that enable a community exercise program to meet the needs of a complex and varied group. Further study will support positive long-term outcomes for people aging with neurological conditions.

Gait speed and spasticity are independently associated with estimated failure load in the distal tibia after stroke: an HR-pQCT study

This HR-pQCT study was conducted to examine bone properties of the distal tibia post-stroke and to identify clinical outcomes that were associated with these properties at this site. It was found that spasticity and gait speed were independently associated with estimated failure load in individuals with chronic stroke.

PURPOSE

(1) To examine the influence of stroke on distal tibia bone properties and (2) the association between these properties and clinical outcomes in people with chronic stroke.

METHODS

Sixty-four people with stroke (age, 60.8 ± 7.7 years; time since stroke, 5.7 ± 3.9 years) and 64 controls (age: 59.4 ± 7.8 years) participated in this study. High-resolution peripheral quantitative computed tomography (HR-pQCT) was used to scan the bilateral distal tibia, and estimated failure load was calculated by automated finite element analysis. Echo intensity of the medial gastrocnemius muscle and blood flow of the popliteal artery were assessed with ultrasound. The 10-m walk test (10MWT), Fugl-Meyer Motor Assessment (FMA), and Composite Spasticity Scale (CSS) were also administered.

RESULTS

The percent side-to-side difference (%SSD) in estimated failure load, cortical area, thickness, and volumetric bone mineral density (vBMD), and trabecular and total vBMD were significantly greater in the stroke group than their control counterparts (Cohen's d = 0.48-1.51). Isometric peak torque and echo intensity also showed significant within- and between-groups differences (p ≤ 0.01). Among HR-pQCT variables, the %SSD in estimated failure load was empirically chosen as one example of the strong discriminators between the stroke group and control group, after accounting for other relevant factors. The 10MWT and CSS subscale for ankle clonus remained significantly associated with the %SSD in estimated failure load after adjusting for other relevant factors (p ≤ 0.05).

CONCLUSION

The paretic distal tibia showed more compromised vBMD, cortical area, cortical thickness, and estimated failure load than the non-paretic tibia. Gait speed and spasticity were independently associated with estimated failure load. As treatment programs focusing on these potentially modifiable stroke-related impairments are feasible to administer, future studies are needed to determine the efficacy of such intervention strategies for improving bone strength in individuals with chronic stroke.

Active Participation of Care Partners in a Physical Activity Intervention Alongside People with Stroke: A Feasibility Study

Purpose: This study investigated the feasibility of a physical activity intervention for people with stroke and their care partners and the role social support plays in physical activity adherence. Method: The study used a single-group, pretest-posttest design with follow-up. Participants were adults with chronic stroke and their care partners. The intervention consisted of 8 weeks of structured, group-based physical activity classes, followed by 19 weeks of self-directed physical activity. Recruitment, adherence, safety, and retention were assessed. Familial social support was assessed before and after the 8-week structured portion and again 19 weeks later. Results: A total of 21 participants (15 people with stroke, 6 care partners), mean age 67.6 (SD 11.6) years, were recruited; 19 (90.5%) completed the 19-week assessment. No adverse events were experienced during the programme. Attendance during the 8-week portion was better than during the 19-week portion (mean difference 0.95; p < 0.001; 95% CI: 0.71, 1.19 visits/wk). No relationship was found between social support and physical activity adherence (p > 0.05). Conclusions: Involvement of care partners in a physical activity intervention is feasible and safe. Both people with stroke and their care partners may require ongoing support to participate in long-term physical activity. The relationship between social support and physical activity adherence requires further study.

Advancing motor rehabilitation for adults with chronic neurological conditions through increased involvement of kinesiologists: a perspective review

Many people with neurological conditions experience challenges with movement. Although rehabilitation is often provided acutely and sub-acutely following the onset of a condition, motor deficits commonly persist in the long-term and are exacerbated by disuse and inactivity. Notably, motor rehabilitation approaches that incorporate exercise and physical activity can support gains in motor function even in the chronic stages of many neurological conditions. However, delivering motor rehabilitation on a long-term basis to people with chronic neurological conditions is a challenge within health care systems, and the onus is often placed on patients to find and pay for services. While neurological motor rehabilitation is largely the domain of physical and occupational therapists, kinesiologists may be able to complement existing care and support delivery of long-term neurological motor rehabilitation, specifically through provision of supported exercise and physical activity programs. In this perspective style review article, we discuss potential contributions of kinesiologists to advancing the field through exercise programming, focusing on community-based interventions that increase physical activity levels. We conclude with recommendations on how kinesiologists' role might be further optimized towards improving long-term outcomes for people with chronic neurological conditions, considering issues related to professional regulation and models of care.

The My Active and Healthy Aging ICT platform prevents quality of life decline in older adults: a randomised controlled study

INTRODUCTION

Prevention of frailty is paramount in older adults. We evaluated the efficacy of a tailored multidomain intervention, monitored with the My Active and Healthy Aging platform, in reducing conversion from a prefrail status to overt frailty and preventing decline in quality of life.

METHODS

We performed a multicentre, multicultural, randomised control study. The effects of multidomain interventions on frailty parameters, quality of life, physical, cognitive, psychosocial function, nutrition and sleep were evaluated in a group of 101 prefrail older subjects and compared with 100 prefrail controls, receiving general health advice.

RESULTS

At the 12-month assessment, controls showed a decline in quality of life that was absent in the active group. In addition, active participants showed an increase in mood and nutrition function. No effect on remaining parameter was observed.

DISCUSSION

Our study supports the use of personalised multidomain intervention, monitored with an information and communication technology platform, in preventing quality of life decline in older adults.

My-AHA: Software Platform to Promote Active and Healthy Ageing

The population is getting old, and the use of technology has improved the quality of life of the senior population. This is confirmed by the increasing number of solutions targeting healthy and active ageing. Such solutions keep track of the daily routine of the elderly and combine it with other relevant information (e.g., biosignals, physical activity, social activity, nutrition) to help identify early signs of decline. Caregivers and elders use this information to improve their routine, focusing on improving the current condition. With that in mind, we have developed a software platform to support My-AHA, which is composed of a multi-platform middleware, a decision support system (DSS), and a dashboard. The middleware seamlessly merges data coming from multiple platforms targeting health and active ageing, the DSS performs an intelligent computation on top of the collected data, and the dashboard provides a user’s interaction with the whole system. To show the potential of the proposed My-AHA software platform, we introduce the My Personal Dashboard web-based application over a frailty use case to illustrate how senior well-being can benefit from the use of technology.

Task-Oriented Circuit Training for Mobility in Outpatient Stroke Rehabilitation in Germany and Austria: A Contextual Transferability Analysis

People with stroke cite mobility deficits as one of the most burdensome limitations. National and international stroke guidelines recommend physical therapy based on task-oriented practice, with high numbers of repetitions to improve mobility. In the outpatient setting in Germany and Austria, these principles have not yet been established. The purpose of this study was to identify an evidence-based intervention that could help reduce this research-practice gap. A stepwise approach proposed by Voigt-Radloff and colleagues and Cochrane Germany was used. First, the specific health service problem in the German and Austrian physical therapy outpatient context was identified. Second, a promising intervention was identified using a systematic search in the Cochrane Library and by grading the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation. Finally, the transferability of the promising intervention into the local context was evaluated using predefined questions from the Cochrane guide and reports from health insurances, professional organizations, and national stroke guidelines. Task-oriented circuit training reviewed by English and colleagues was chosen. The review showed clinically important improvements in walking distance and speed. The quality of the evidence was graded high for these 2 outcomes. We identified contextual challenges for implementation at the setting level (eg, insufficient reimbursement for group therapy by insurance companies), the participant and therapist level (eg, unknown motivation for group therapy due to the established 1:1 patient-therapist ratio), and the outcome measure level (eg, lack of standardized, cross-culturally translated manuals). Although task-oriented circuit training is scientifically well established, barriers to implementation into routine care in Germany and Austria can be expected. In a next step, research using knowledge translation methodology will focus on the detailed evaluation of barriers and facilitators with relevant stakeholders.

Balance Training with Electromyogram-Triggered Functional Electrical Stimulation in the Rehabilitation of Stroke Patients

This study was conducted to investigate the effects of balance training with electromyogram-triggered functional electrical stimulation (EMG-triggered FES) to improve static balance, dynamic balance, and ankle muscle activation in stroke patients. Forty-nine participants (>6 months after stroke) were randomly assigned to the experimental group (n = 25) and the control group (n = 24). The experimental group underwent balance training with EMG-triggered FES for 40 min a day, 5 days a week, for a 6-week period in addition to general rehabilitation. The control group underwent balance training without EMG-triggered FES along with conventional therapy. Outcome measures included static balance ability, dynamic balance ability, and leg muscle activation. The static and dynamic balance abilities were significantly improved after intervention in both groups (p < 0.05), although the experimental group showed considerably greater improvement than the control group (p < 0.05). Leg muscle activation on the affected side resulted in significant improvements in the experimental group (p < 0.05) when compared with baseline but not in the control group. Balance training with EMG-triggered FES is an acceptable and effective intervention to improve the static balance, dynamic balance, and ankle muscle activation in stroke patients.

Structuring community-based adapted dance programs for persons post-stroke: a qualitative study

PURPOSE

Dance improves physical, psychosocial, and cognitive function, while increasing community participation among community-dwelling individuals post-stroke. Yet little is known about how to structure community-based dance classes to optimize benefits and participation. This study aims to gain stakeholders' perspectives about how to optimally structure community-based dance classes for individuals with chronic stroke.

METHODS

A qualitative descriptive approach utilizing focus group methods was implemented. Two focus groups were undertaken with each of three stakeholder groups: persons post-stroke (n = 9), rehabilitation therapists (n = 6), and dance instructors (n = 8). Focus groups were audio-recorded and transcribed verbatim, providing the raw data. Analysis of the focus group transcripts were completed using the DEPICT model of collaborative qualitative analysis.

RESULTS

This study identified three main themes/topics requiring consideration when structuring community-based dance programs: the environment, flow of the class, and qualities of the dance instructor. The study findings highlight that the pedagogical skills and teaching philosophy of the dance instructor are integral for a successful dance program, as the dance instructor directly mediates both the environment and flow of classes.

CONCLUSION

Recommendations generated from our study can inform the development of community-based dance programs that are practical, optimize health benefits, and meet the needs and interests of people post-stroke.IMPLICATIONS FOR REHABILITATIONDance is an effective way to improve physical, psychosocial, and cognitive function for persons post-stroke while also promoting meaningful social relationships within the community.A dance instructor who is a skilled communicator and is willing to adapt to the needs of the class, is the most important factor for a successful dance class.Creating a safe and inviting environment for a dance program, includes both the physical and emotional aspects of environment facilitating individuals to create connections with others and feel more confident in themselves.The structure of a dance class, based on the abilities, interests, and goals of dancers, should include elements of predictability and variability to keep dancers progressing and motivated, and be two times a week for 3 months lasting 1-2 h.

Interventions for preventing falls in people after stroke

BACKGROUND

Falls are one of the most common complications after stroke, with a reported incidence ranging between 7% in the first week and 73% in the first year post stroke. This is an updated version of the original Cochrane Review published in 2013.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at preventing falls in people after stroke. Our primary objective was to determine the effect of interventions on the rate of falls (number of falls per person-year) and the number of fallers. Our secondary objectives were to determine the effects of interventions aimed at preventing falls on 1) the number of fall-related fractures; 2) the number of fall-related hospital admissions; 3) near-fall events; 4) economic evaluation; 5) quality of life; and 6) adverse effects of the interventions.

SEARCH METHODS

We searched the trials registers of the Cochrane Stroke Group (September 2018) and the Cochrane Bone, Joint and Muscle Trauma Group (October 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 9) in the Cochrane Library; MEDLINE (1950 to September 2018); Embase (1980 to September 2018); CINAHL (1982 to September 2018); PsycINFO (1806 to August 2018); AMED (1985 to December 2017); and PEDro (September 2018). We also searched trials registers and checked reference lists.

SELECTION CRITERIA

Randomised controlled trials of interventions where the primary or secondary aim was to prevent falls in people after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors (SD and WS) independently selected studies for inclusion, assessed trial quality and risk of bias, and extracted data. We resolved disagreements through discussion, and contacted study authors for additional information where required. We used a rate ratio and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person-year) between intervention and control groups. For risk of falling we used a risk ratio and 95% CI based on the number of people falling (fallers) in each group. We pooled results where appropriate and applied GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 14 studies (of which six have been published since the first version of this review in 2013), with a total of 1358 participants. We found studies that investigated exercises, predischarge home visits for hospitalised patients, the provision of single lens distance vision glasses instead of multifocal glasses, a servo-assistive rollator and non-invasive brain stimulation for preventing falls.Exercise compared to control for preventing falls in people after strokeThe pooled result of eight studies showed that exercise may reduce the rate of falls but we are uncertain about this result (rate ratio 0.72, 95% CI 0.54 to 0.94, 765 participants, low-quality evidence). Sensitivity analysis for single exercise interventions, omitting studies using multiple/multifactorial interventions, also found that exercise may reduce the rate of falls (rate ratio 0.66, 95% CI 0.50 to 0.87, 626 participants). Sensitivity analysis for the effect in the chronic phase post stroke resulted in little or no difference in rate of falls (rate ratio 0.58, 95% CI 0.31 to 1.12, 205 participants). A sensitivity analysis including only studies with low risk of bias found little or no difference in rate of falls (rate ratio 0.88, 95% CI 0.65 to 1.20, 462 participants). Methodological limitations mean that we have very low confidence in the results of these sensitivity analyses.For the outcome of number of fallers, we are very uncertain of the effect of exercises compared to the control condition, based on the pooled result of 10 studies (risk ratio 1.03, 95% CI 0.90 to 1.19, 969 participants, very low quality evidence). The same sensitivity analyses as described above gives us very low certainty that there are little or no differences in number of fallers (single interventions: risk ratio 1.09, 95% CI 0.93 to 1.28, 796 participants; chronic phase post stroke: risk ratio 0.94, 95% CI 0.73 to 1.22, 375 participants; low risk of bias studies: risk ratio 0.96, 95% CI 0.77 to 1.21, 462 participants).Other interventions for preventing falls in people after strokeWe are very uncertain whether interventions other than exercise reduce the rate of falls or number of fallers. We identified very low certainty evidence when investigating the effect of predischarge home visits (rate ratio 0.85, 95% CI 0.43 to 1.69; risk ratio 1.48, 95% CI 0.71 to 3.09; 85 participants), provision of single lens distance glasses to regular wearers of multifocal glasses (rate ratio 1.08, 95% CI 0.52 to 2.25; risk ratio 0.74, 95% CI 0.47 to 1.18; 46 participants) and a servo-assistive rollator (rate ratio 0.44, 95% CI 0.16 to 1.21; risk ratio 0.44, 95% CI 0.16 to 1.22; 42 participants).Finally, transcranial direct current stimulation (tDCS) was used in one study to examine the effect on falls post stroke. We have low certainty that active tDCS may reduce the number of fallers compared to sham tDCS (risk ratio 0.30, 95% CI 0.14 to 0.63; 60 participants).

AUTHORS' CONCLUSIONS

At present there exists very little evidence about interventions other than exercises to reduce falling post stroke. Low to very low quality evidence exists that this population benefits from exercises to prevent falls, but not to reduce number of fallers.Fall research does not in general or consistently follow methodological gold standards, especially with regard to fall definition and time post stroke. More well-reported, adequately-powered research should further establish the value of exercises in reducing falling, in particular per phase, post stroke.

Trend of the burden of chronic illnesses: using the Canadian Community Health Survey

OBJECTIVES

Burden of illnesses has been described in the literature using the health-related quality of life (HRQoL) in people with chronic conditions. However, the studies reporting trends of burden are sparse. The aim of this study was to explore the trends of burden of chronic illness from the perspective of HRQoL.

STUDY DESIGN

This was a secondary analysis of administrative database.

METHODS

Seven data sets of the Canadian Community Health Survey from 2001 to 2014 were obtained for the analysis. Multiple linear and logistic regression models were used on each data set to assess the burden of illness on the Health Utilities Index Mark III (HUI₃), life satisfaction (LS), and perceived health (PH).

RESULTS

People with the effect of stroke constantly had low scores on the HUI₃, LS, and PH. Regression analyses revealed that arthritis, back problem, and mood disorder have greater impact on the HUI₃ score. Effect of stroke, mood disorder, and anxiety disorder stably had the largest negative impact on LS, while chronic obstructive pulmonary disease (COPD), effect of stroke, and cancer had the largest effect on PH.

CONCLUSION

This study identified that arthritis, back pain, mood disorder, effect of stroke, and COPD constantly have high burden on health outcomes compared with other chronic condition over the past decade.

The My Active and Healthy Aging (My-AHA) ICT platform to detect and prevent frailty in older adults: Randomized control trial design and protocol

INTRODUCTION

Frailty increases the risk of poor health outcomes, disability, hospitalization, and death in older adults and affects 7%-12% of the aging population. Secondary impacts of frailty on psychological health and socialization are significant negative contributors to poor outcomes for frail older adults.

METHOD

The My Active and Healthy Aging (My-AHA) consortium has developed an information and communications technology-based platform to support active and healthy aging through early detection of prefrailty and provision of individually tailored interventions, targeting multidomain risks for frailty across physical activity, cognitive activity, diet and nutrition, sleep, and psychosocial activities. Six hundred adults aged 60 years and older will be recruited to participate in a multinational, multisite 18-month randomized controlled trial to test the efficacy of the My-AHA platform to detect prefrailty and the efficacy of individually tailored interventions to prevent development of clinical frailty in this cohort. A total of 10 centers from Italy, Germany, Austria, Spain, United Kingdom, Belgium, Sweden, Japan, South Korea, and Australia will participate in the randomized controlled trial.

RESULTS

Pilot testing (Alpha Wave) of the My-AHA platform and all ancillary systems has been completed with a small group of older adults in Europe with the full randomized controlled trial scheduled to commence in 2018.

DISCUSSION

The My-AHA study will expand the understanding of antecedent risk factors for clinical frailty so as to deliver targeted interventions to adults with prefrailty. Through the use of an information and communications technology platform that can connect with multiple devices within the older adult's own home, the My-AHA platform is designed to measure an individual's risk factors for frailty across multiple domains and then deliver personalized domain-specific interventions to the individual. The My-AHA platform is technology-agnostic, enabling the integration of new devices and sensor platforms as they emerge.

Cellular and Molecular Mechanisms Underlying Non-Pharmaceutical Ischemic Stroke Therapy in Aged Subjects

The incidence of ischemic stroke in humans increases exponentially above 70 years both in men and women. Comorbidities like diabetes, arterial hypertension or co-morbidity factors such as hypercholesterolemia, obesity and body fat distribution as well as fat-rich diet and physical inactivity are common in elderly persons and are associated with higher risk of stroke, increased mortality and disability. Obesity could represent a state of chronic inflammation that can be prevented to some extent by non-pharmaceutical interventions such as calorie restriction and hypothermia. Indeed, recent results suggest that H₂S-induced hypothermia in aged, overweight rats could have a higher probability of success in treating stroke as compared to other monotherapies, by reducing post-stroke brain inflammation. Likewise, it was recently reported that weight reduction prior to stroke, in aged, overweight rats induced by caloric restriction, led to an early re-gain of weight and a significant improvement in recovery of complex sensorimotor skills, cutaneous sensitivity, or spatial memory.

CONCLUSION

animal models of stroke done in young animals ignore age-associated comorbidities and may explain, at least in part, the unsuccessful bench-to-bedside translation of neuroprotective strategies for ischemic stroke in aged subjects.

Factors Influencing the Efficacy of Aerobic Exercise for Improving Fitness and Walking Capacity After Stroke: A Meta-Analysis With Meta-Regression

OBJECTIVE

To assess the influence of dosing parameters and patient characteristics on the efficacy of aerobic exercise (AEX) poststroke.

DATA SOURCES

A systematic review was conducted using PubMed, MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Physiotherapy Evidence Database, and Academic Search Complete.

STUDY SELECTION

Studies were selected that compared an AEX group with a nonaerobic control group among ambulatory persons with stroke.

DATA EXTRACTION

Extracted outcome data included peak oxygen consumption (V˙o₂peak) during exercise testing, walking speed, and walking endurance (6-min walk test). Independent variables of interest were AEX mode (seated or walking), AEX intensity (moderate or vigorous), AEX volume (total hours), stroke chronicity, and baseline outcome scores.

DATA SYNTHESIS

Significant between-study heterogeneity was confirmed for all outcomes. Pooled AEX effect size estimates (AEX group change minus control group change) from random effects models were V˙o₂peak, 2.2mL⋅kg^-1⋅min^-1 (95% confidence interval [CI], 1.3-3.1mL⋅kg^-1⋅min^-1); walking speed, .06m/s (95% CI, .01-.11m/s); and 6-minute walk test distance, 29m (95% CI, 15-42m). In meta-regression, larger V˙o₂peak effect sizes were significantly associated with higher AEX intensity and higher baseline V˙o₂peak. Larger effect sizes for walking speed and the 6-minute walk test were significantly associated with a walking AEX mode. In contrast, seated AEX did not have a significant effect on walking outcomes.

CONCLUSIONS

AEX significantly improves aerobic capacity poststroke, but may need to be task specific to affect walking speed and endurance. Higher AEX intensity is associated with better outcomes. Future randomized studies are needed to confirm these results.

Exercise and Environmental Enrichment as Enablers of Task-Specific Neuroplasticity and Stroke Recovery

Improved stroke care has resulted in greater survival, but >50% of patients have chronic disabilities and 33% are institutionalized. While stroke rehabilitation is helpful, recovery is limited and the most significant gains occur in the first 2-3 months. Stroke triggers an early wave of gene and protein changes, many of which are potentially beneficial for recovery. It is likely that these molecular changes are what subserve spontaneous recovery. Two interventions, aerobic exercise and environmental enrichment, have pleiotropic actions that influence many of the same molecular changes associated with stroke injury and subsequent spontaneous recovery. Enrichment paradigms have been used for decades in adult and neonatal animal models of brain injury and are now being adapted for use in the clinic. Aerobic exercise enhances motor recovery and helps reduce depression after stroke. While exercise attenuates many of the signs associated with normal aging (e.g., hippocampal atrophy), its ability to reverse cognitive impairments subsequent to stroke is less evident. It may be that stroke, like other diseases such as cancer, needs to use multimodal treatments that augment complimentary neurorestorative processes.

Video-games used in a group setting is feasible and effective to improve indicators of physical activity in individuals with chronic stroke: a randomized controlled trial

OBJECTIVES

To investigate the feasibility of using video-games in a group setting and to compare the effectiveness of video-games as a group intervention to a traditional group intervention for improving physical activity in individuals with chronic stroke.

DESIGN

A single-blind randomized controlled trial with evaluations pre and post a 3-month intervention, and at 3-month follow-up. Compliance (session attendance), satisfaction and adverse effects were feasibility measures. Grip strength and gait speed were measures of physical activity. Hip accelerometers quantified steps/day and the Action Research Arm Test assessed the functional ability of the upper extremity.

RESULTS

Forty-seven community-dwelling individuals with chronic stroke (29-78 years) were randomly allocated to receive video-game (N=24) or traditional therapy (N=23) in a group setting. There was high treatment compliance for both interventions (video-games-78%, traditional therapy-66%), but satisfaction was rated higher for the video-game (93%) than the traditional therapy (71%) (χ(2)=4.98, P=0.026). Adverse effects were not reported in either group. Significant improvements were demonstrated in both groups for gait speed (F=3.9, P=0.02), grip strength of the weaker (F=6.67, P=0.002) and stronger hands (F=7.5, P=0.001). Daily steps and functional ability of the weaker hand did not increase in either group.

CONCLUSIONS

Using video-games in a small group setting is feasible, safe and satisfying. Video-games improve indicators of physical activity of individuals with chronic stroke.

Motivators for uptake and maintenance of exercise: perceptions of long-term stroke survivors and implications for design of exercise programmes

PURPOSE

Exercise-after-stroke programmes are increasingly being provided to encourage more physical exercise among stroke survivors, but little is known about what motivates people with stroke to participate in them. This research aimed to identify factors that motivate long-term stroke survivors to exercise, and the implications for programme design.

METHODS

In two separate studies, focus groups and individual interviews were used to investigate the views of long-term stroke survivors on exercise and participating in exercise programmes. Their data were analysed thematically, and the findings of the studies were synthesised.

RESULTS

Eleven stroke survivors and two partners took part in two focus groups; six other stroke survivors (one with a partner) were interviewed individually. Factors reported to influence motivation were the psychological benefits of exercise, a desire to move away from a medicalised approach to exercise, beliefs about stroke recovery, and on-going support to sustain commitment. A number of potential implications of these themes for exercise programme design were identified.

CONCLUSIONS

A range of personal beliefs and attitudes and external factors may affect the motivation to exercise, and these vary between individuals. Addressing these factors in the design of exercise programmes for long-term stroke survivors may enhance their appeal and so encourage greater engagement in exercise.

IMPLICATIONS FOR REHABILITATION

Exercise programmes may be more attractive to long-term stroke survivors if the psychological well-being benefits of participation are emphasised in their promotion. Some participants will be more attracted by programmes that are de-medicalised, for example, by being located away from clinical settings, and led by or involving suitably-trained non-clinicians. Programmes offered in different formats may attract stroke survivors with different beliefs about the value of exercise in stroke recovery. Programmes should provide explicit support strategies for on-going engagement in exercise.

Interventions for preventing falls in people after stroke

BACKGROUND

Falls are one of the most common medical complications after stroke with a reported incidence of 7% in the first week after stroke onset. Studies investigating falls in the later phase after stroke report an incidence of up to 73% in the first year post-stroke.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at preventing falls in people after stroke.

SEARCH METHODS

We searched the trials registers of the Cochrane Stroke Group (November 2012) and the Cochrane Bone, Joint and Muscle Trauma Group (May 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2012, Issue 5, MEDLINE (1950 to May 2012), EMBASE (1980 to May 2012), CINAHL (1982 to May 2012), PsycINFO (1806 to May 2012), AMED (1985 to May 2012) and PEDro (May 2012). We also searched trials registers, checked reference lists and contacted authors.

SELECTION CRITERIA

Randomised controlled trials of interventions where the primary or secondary aim was to prevent falls in people after stroke.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies for inclusion, assessed trial quality, and extracted data. We used a rate ratio and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling we used a risk ratio and 95% CI based on the number of people falling (fallers) in each group. We pooled results where appropriate.

MAIN RESULTS

We included 10 studies with a total of 1004 participants. One study evaluated the effect of exercises in the acute and subacute phase after stroke but found no significant difference in rate of falls (rate ratio 0.92, 95% CI 0.45 to 1.90, 95 participants). The pooled result of four studies investigating the effect of exercises on preventing falls in the chronic phase also found no significant difference for rate of falls (rate ratio 0.75, 95% CI 0.41 to 1.38, 412 participants).For number of fallers, one study examined the effect of exercises in the acute and subacute phase after stroke but found no significant difference between the intervention and control group (risk ratio 1.19, 95% CI 0.83 to 1.71, 95 participants). The pooled result of six studies examining the effect of exercises in the chronic phase also found no significant difference in number of fallers between the intervention and control groups (risk ratio 1.02, 95% CI 0.83 to 1.24, 616 participants).The rate of falls and the number of fallers was significantly reduced in two studies evaluating the effect of medication on preventing falls; one study (85 participants) compared vitamin D versus placebo in institutionalised women after stroke with low vitamin D levels, and the other study (79 participants) evaluated alendronate versus alphacalcidol in hospitalised people after stroke.One study provided single lens distance glasses to regular wearers of multifocal glasses. In a subgroup of 46 participants post-stroke there was no significant difference in the rate of falls (rate ratio 1.08, 95% CI 0.52 to 2.25) or the number of fallers between both groups (risk ratio 0.74, 95% CI 0.47 to 1.18).

AUTHORS' CONCLUSIONS

There is currently insufficient evidence that exercises or prescription of single lens glasses to multifocal users prevent falls or decrease the number of people falling after being discharged from rehabilitation following their stroke. Two studies testing vitamin D versus placebo and alendronate versus alphacalcidol found a significant reduction in falls and the number of people falling. However, these findings should be replicated before the results are implemented in clinical practice.