"Task-oriented" exercise improves hamstring strength and spastic reflexes in chronic stroke patients

A rehabilitative approach beyond the acute stroke event: a scoping review about functional recovery perspectives in the chronic hemiplegic patient

Background

Stroke is a main cause of disability worldwide and its neuro-rehabilitative management is not limited to the acute phase but requires continuity in the rehabilitation approach especially in the chronic phase. The aim of this scoping review was to highlight the different treatment opportunities available in neurorehabilitation, effective for patients with chronic stroke sequelae, not only in terms of maintaining motor function but also improving it.

Methods

The literature search was conducted using the following databases: MEDLINE (PubMed), PEDro, Scopus, Web of Science (WOS), Cochrane from 2012 to February 2023. We selected Randomized Clinical Trials in English dealing with neurorehabilitation strategies in chronic hemiplegic patients after stroke focusing on motor function, muscular strength, gait, postural balance, spasticity, and quality of life.

Results

According to the inclusion criteria, 47 articles were selected for our review. All of them were analyzed following the primary outcome and the rehabilitation technique used. Despite the different protocols used within the same technique and despite the chronicity of the disease, all studies report an improvement after the rehabilitation treatment of motor function and quality of life.

Conclusion

The literature analyzed invites us to reflect respect to neurorehabilitation approach to the patient with chronic stroke sequelae often considered to have as its objective the maintenance of the present motor function and contain disability: instead, the review reports how, even in chronicity, the patient always reports margins of statistically and clinically significant improvement. The chronic stroke rehabilitation over 6 months has been proved effective in obtaining recovery in different settings.

Exercise and Stroke

Stroke is a leading cause of mortality and morbidity all around the world. Identification of stroke risk factors and protective lifestyles is necessary for optimizing personalized treatment and reducing mortality. Sedentary lifestyle is a well-known modifiable risk factor in primary and secondary stroke prevention. Also, in recent years, exercise has been described as a neuroprotective and neuroreparative factor. Here we summarized the existing available evidence of the relationship between physical activity and stroke.

Mirror therapy and treadmill training for patients with chronic stroke: a pilot randomized controlled trial

BACKGROUND

Previous lower-limb mirror therapy research has focused on non-weight bearing interventions.

OBJECTIVES

The primary aim of this study was to investigate the effect and feasibility of a combination of mirror therapy and treadmill training on post-stroke lower-limb recovery compared to a placebo intervention.

METHODS

All patients (N = 30) walked on a treadmill for 30 min per day, 3 days per week, for 4 weeks. The mirror therapy and treadmill training group (n = 15) walked on the treadmill while viewing a reflection of their non-paretic limb in a mirror positioned in their mid-sagittal plane. The placebo group (n = 15) received no mirror visual feedback due to an altered mirror position.

PRIMARY OUTCOME MEASURES

Ten Metre Walk Test (10MWT) and Six Minute Walk Test (6MWT).

SECONDARY OUTCOME MEASURES

Modified Ashworth Scale (MAS) and Fugl-Meyer Assessment-Lower Extremity (FMA-LE). Feasibility was appraised by examining participant compliance and any adverse events.

RESULTS

No significant between group differences were demonstrated for the 10MWT, 6MWT or FMA-LE at post-training or 3-month follow-up assessment. A significant between group difference on the MAS was demonstrated in the reduction of ankle dorsiflexion muscle tone (p = 0.006) and ankle plantarflexion muscle tone (p = 0.01) in the mirror therapy group compared to the placebo group at post-training assessment but not at 3-month follow-up.

CONCLUSION

Our study reveals that in our group of patients with chronic stroke, mirror therapy combined with treadmill training facilitated significant reductions in ankle muscle tone (p < 0.05) compared to a placebo intervention.

Mirror therapy and treadmill training for a patient with chronic stroke: A case report

INTRODUCTION

A large proportion of patients with chronic stroke have permanent lower limb functional disability leading to reduced levels of independent mobility. Individually, both mirror therapy and treadmill training have been shown to improve aspects of lower limb functioning in patients with stroke. This case report examined whether a new combination of both interventions would lead to improvements in lower limb functional disability for a patient with chronic stroke.

CASE DESCRIPTION

The participant was a 50-year-old female who had a left middle cerebral artery infarction (47 months' post stroke). Due to hemiparesis, she had lower limb motor impairment and gait deficits.

INTERVENTION

The participant engaged in a combination of mirror therapy and treadmill training for 30 minutes per day, 3 days per week, for 4 weeks.

OUTCOMES

Modified Ashworth Scale, Fugl-Meyer Assessment-Lower Extremity and the 10 m Walk Test demonstrated clinically meaningful change. The 6 Minute Walk Test did not demonstrate meaningful change.

DISCUSSION

The positive outcomes from this new combination therapy for this participant are encouraging given the relatively small dose of training and indicate the potential benefit of mirror therapy as an adjunct to treadmill training for enhancing lower limb muscle tone, motor function and walking velocity in patients with chronic stroke.

Effects of gait training with non-paretic knee immobilization on patients with hemiplegia: Three single-case studies

Patients' with a hemiplegic gait and difficulties with activities of daily living may improve through intensive training of their paretic lower limbs. This study examined the possibility of improving their gait by immobilizing the non-paretic knee joint in extension and promoting weight shift toward the paretic side. Single-case ABABA studies were conducted, involving three patients with hemiplegia. The patients walked with their non-paretic knee joints immobilized in extension using a dial-lock knee orthosis during the intervention (B1 and B2) periods. Measurement items included (1) temporal and distance factors and (2) hip, knee, and ankle joint angles during gait. In all subjects, the stance phase was significantly prolonged on the paretic side during all intervention periods following the first baseline (A1) period. In Subject 1, hip extension in the stance phase improved during all intervention periods following the A1 period, and, in Subjects 2 and 3, the knee hyperextension in the stance phase, which was observed during the A1 period, was resolved during the second (A2) and third (A3) baseline periods. Gait training with non-paretic knee immobilization may promote weight shift toward the paretic side to overcome a swing limitation on the immobilized side, consequently providing an opportunity for training in weight bearing for the paretic limb and an improved, more symmetrical gait pattern.

ReHabgame: A non-immersive virtual reality rehabilitation system with applications in neuroscience

This paper proposes the use of a non-immersive virtual reality rehabilitation system “ReHabgame” developed using Microsoft Kinect™ and the Thalmic™ Labs Myo gesture control armband. The ReHabgame was developed based on two third-person video games that provide a feasible possibility of assessing postural control and functional reach tests. It accurately quantifies specific postural control mechanisms including timed standing balance, functional reach tests using real-time anatomical landmark orientation, joint velocity, and acceleration while end trajectories were calculated using an inverse kinematics algorithm. The game was designed to help patients with neurological impairment to be subjected to physiotherapy activity and practice postures of daily activities. The subjective experience of the ReHabgame was studied through the development of an Engagement Questionnaire (EQ) for qualitative, quantitative and Rasch model.

The Monte-Carlo Tree Search (MCTS) and Random object (ROG) generator algorithms were used to adapt the physical and gameplay intensity in the ReHabgame based on the Motor Assessment Scale (MAS) and Hierarchical Scoring System (HSS). Rasch analysis was conducted to assess the psychometric characteristics of the ReHabgame and to identify if these are any misfitting items in the game.

Rasch rating scale model (RSM) was used to assess the engagement of players in the ReHabgame and evaluate the effectiveness and attractiveness of the game. The results showed that the scales assessing the rehabilitation process met Rasch expectations of reliability, and unidimensionality. Infit and outfit mean squares values are in the range of (0.68–1.52) for all considered 16 items. The Root Mean Square Residual (RMSR) and the person separation reliability were acceptable. The item/person map showed that the persons and items were clustered symmetrically.

Aerobic Exercise Prescription in Stroke Rehabilitation: A Web-Based Survey of US Physical Therapists

BACKGROUND AND PURPOSE

Best practice recommendations indicate that aerobic exercise (AEX) should be incorporated into stroke rehabilitation. However, this may be challenging in clinical settings. The purpose of this study was to assess physical therapist (PT) AEX prescription for patients with stroke, including AEX utilization, barriers to AEX prescription, dosing parameters, and safety considerations.

METHODS

A cross-sectional Web-based survey study was conducted. Physical therapists with valid e-mail addresses on file with the state boards of Florida, New Jersey, Ohio, Texas, and Wyoming were eligible to participate. Survey invitations were e-mailed to all licensed PT in these states. Analysis focused on respondents who were currently involved with clinical stroke rehabilitation in common practice settings.

RESULTS

Results from 568 respondents were analyzed. Most respondents (88%) agreed that AEX should be incorporated into stroke rehabilitation, but 84% perceived at least one barrier. Median prescribed AEX volume varied between practice settings from 20- to 30-minute AEX sessions, 3 to 5 days per week for 2 to 8 weeks. Prescribed intensity was most commonly light or moderate; intensity was determined by the general response to AEX and patient feedback. Only 2% of respondents reported that the majority of their patients with stroke had stress tests.

DISCUSSION AND CONCLUSIONS

Most US PTs appear to recognize the importance of AEX for persons poststroke, but clinical implementation can be challenging. Future studies and consensus are needed to clarify best practices and to develop implementation interventions to optimize AEX utilization in stroke rehabilitation.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A167).

Effects of Novel Guidance Tubing Gait on Electromyographic Neuromuscular Imbalance and Joint Angular Kinematics During Locomotion in Hemiparetic Stroke Patients

OBJECTIVE

To compare the immediate effects of conventional treadmill gait and guidance tubing gait (GTG) on electromyographic neuromuscular imbalance and knee joint kinematics in hemiparetic gait.

DESIGN

Case-control study.

SETTING

University medical center.

PARTICIPANTS

Participants (N=33; 19 men, 14 women) were patients with hemiparetic stroke (n=18 [experimental]; mean age ± SD, 39.2±16.8y) and healthy controls (n=15; mean age ± SD, 26.3±2.6y).

INTERVENTIONS

The GTG was provided for approximately 30 minutes and involved application of an assistive guidance force using the tubing, specifically to improve knee joint stabilization during midstance and increase knee joint flexion during midswing phase.

MAIN OUTCOME MEASURES

Clinical tests included the Korean Mini-Mental State Examination, Modified Ashworth Scale, Berg Balance Scale, manual muscle test, and knee joint range of motion and sensory tests. Knee joint muscle electromyographic and kinematic analyses were determined at pretest and posttest.

RESULTS

After the intervention, the experimental group showed significantly greater improvements in balanced quadriceps and hamstring electromyographic coactivation and knee joint kinematics relative to the control group (P=.005). The GTG intervention decreased overactive hamstring activity (P=.018) and reciprocally increased quadriceps activity (P<.001). The knee joint kinematic analysis showed significant changes in the hemiparetic stroke group (P=.004).

CONCLUSIONS

This study demonstrates the effectiveness of the tubing gait condition to restore knee joint muscle imbalance and kinematics in individuals with hemiparetic stroke who present with an abnormal hyperextension knee gait.

The effect of Monkey Chair and Band exercise system on shoulder range of motion and pain in post-stroke patients with hemiplegia

[Purpose] A simple rehabilitation device system for strengthening upper limb muscles in hemiplegic patients was developed. This system, which stimulates active exercise while accounting for intensity, time, and frequency, was examined in the present pilot study. [Subjects and Methods] Patients had shoulder pain and limited shoulder movement. Changes in range of motion (ROM) and scores of a visual analog scale (VAS) for pain were evaluated in the experimental and control groups every four weeks for twelve weeks. The modified motor assessment scale (MMAS) was used before and after experiments. [Results] Significant differences between experimental times in ROM for shoulder flexion, abduction, and adduction on the paralyzed side were observed in the experimental group at every time point. Pain VAS scores in the experimental group improved progressively and significantly with time, indicating a consistently increasing effect of exercise. There were significant differences between the MMAS scores before and after completion of the program in the experimental group. [Conclusion] Muscle strengthening is important in hemiplegic patients, and active exercise was more efficient than passive exercise in this regard. Rehabilitation with the Monkey Chair and Band system may represent an efficient and important tool in upper limb training and comprehensive modern rehabilitation therapy.

Family caregivers' experience of activities of daily living handling in older adult with stroke: a qualitative research in the Iranian context

BACKGROUND

Patients with stroke require additional support from family to live independently in the area of activities of daily living. Family members are usually the main caregivers of stroke patients. Comprehensive explanation of ADL handling from family caregivers' view is lacking.

AIM

This study explores and describes family caregivers' experiences about the strategies to handle activities of daily living (ADL) dependency of elderly patient with stroke in the Iranian context.

METHOD

A qualitative content analysis approach was conducted to analyse data. Nineteen family caregivers participated in the study from multiple physiotherapy clinics of physiotherapy in Sari (Iran) between September 2013 and May 2014. Data were generated through in-depth interviews, and content analysis method was used to analyse the data and determine themes.

FINDINGS

The findings show that family caregivers manage the ADL dependency of their elderly stroke patients through seven strategies including encouraging physical movements, providing personal hygiene, nutritional consideration, facilitating religious activities, filling leisure time, and facilitating transfer and assisting in financial issues.

CONCLUSION

Family has an important role in handling of elderly stroke patients' ADL dependency. Health practitioners can take benefit from the findings to help the stroke families play more active role in the handling ADL dependency of their patients after stroke.

The adjunctive role of mental practice in the rehabilitation of the upper limb after hemiplegic stroke: a pilot studya

Objective: To assess the feasibility and practicalities of using the technique of mental practice as an adjunct in the rehabilitation of the upper limb following stroke.

Design: A series of single-case studies.

Setting: A stroke rehabilitation unit in Belfast.

Subjects: Fourteen patients admitted for rehabilitation of their first stroke: six men and four women, aged 45–81 between 10 and 176 days post stroke.

Intervention: Each patient underwent a single-case design, with two weeks baseline, two weeks intervention and one week withdrawal. The intervention consisted of structured daily mental practice sessions of a reach and grasp task, in addition to their usual therapy.

Main outcome measures: The upper limb component of the Motricity Index was used to grade motor activity sequentially across the timescale of the study.

Results: Of the 14 patients recruited, four withdrew and 10 completed the study. Nine showed improvement in upper limb Motricity Index score with mental practice as measured by the two-band standard deviation method. One of these cases demonstrated an unstable baseline such that changes could not be attributed to intervention.

Conclusions: This pilot study suggests that mental practice may be useful as an adjunct to physiotherapy after stroke.

Effects of Functional Limb Overloading on Symmetrical Weight Bearing, Walking Speed, Perceived Mobility, and Community Participation among Patients with Chronic Stroke

Background. Stroke is a leading cause for long-term disability that often compromises the sensorimotor and gait function accompanied by spasticity. Gait abnormalities persist through the chronic stages of the condition and only a small percentage of these persons are able to walk functionally in the community. Material and Method. Patients with chronic stroke were recruited from outpatient rehabilitation unit at Department of Neurology & Neurosurgery, All India Institute of Medical Sciences, having a history of first stroke at least six months before recruitment, with unilateral motor deficits affecting gait. The patients were randomly assigned to either the functional limb overloading (FLO) or Limb Overloading Resistance Training (LORT) group and provided four weeks of training. Result. We found that there was an improvement in gait performance, weight bearing on affected limb, and perceived mobility and community participation. Conclusion. To the best of our knowledge, this is the first study that has evaluated the effects of functional limb overloading training on symmetric weight bearing, walking ability, and perceived mobility and participation in chronic hemiplegic population. The study demonstrated a beneficial effect of training on all the outcomes, suggesting that the functional limb overloading training can be a useful tool in the management of gait problems in chronic stroke patients.

Effects of underwater treadmill walking training on the peak torque of the knee in hemiplegic patients

[Purpose] This study investigated the effects of underwater treadmill walking training on the peak torque of the knee in hemiplegic patients. [Subjects and Methods] Thirty-two subjects, who were randomly allocated to an experimental group (n=16) and a control group (n=16), performed underwater treadmill walking training and overground treadmill walking training, respectively, for 30 minutes/session, 3 sessions/week, for 6 weeks. An isokinetic dynamometer was used to assess the peak torque. [Results] The subjects in the experimental group showed an increase in the peak knee extension torque compared to the control group. [Conclusion] The results suggested that underwater treadmill walking training has a greater effect on peak knee extension torque at velocities of 60°/sec and 120°/sec than overground treadmill walking training.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

The Role of Task-Specific Training in Rehabilitation Therapies

Task-oriented therapy is important. It makes intuitive sense that the best way to relearn a given task is to train specifically for that task. In animals, functional reorganization is greater for tasks that are meaningful to the animal. Repetition alone, without usefulness or meaning in terms of function, is not enough to produce increased motor cortical representations. In humans, less intense but task-specific training regimens with the more affected limb can produce cortical reorganization and associated, meaningful functional improvements.

Task-Oriented Aerobic Exercise in Chronic Hemiparetic Stroke: Training Protocols and Treatment Effects

Stroke is the leading cause of disability in older Americans. Each year 750,000 Americans suffer a stroke, two thirds of whom are left with neurological deficits that persistently impair function. Principal among them is hemiparetic gait that limits mobility and increases fall risk, promoting a sedentary lifestyle. These events propagate disability by physical deconditioning and "learned non-use," with further functional declines accelerated by the sarcopenia and fitness decrements of advancing age. Conventional rehabilitation care typically provides little or no structured therapeutic exercise beyond the subacute stroke recovery period, based on natural history studies showing little or no further functional motor recovery beyond 6 months after stroke. Emerging evidence suggests that new models of task-oriented exercise have the potential to improve motor function even years after stroke. This article presents treadmill as a task-oriented training paradigm to optimize locomotor relearning while eliciting cardiovascular conditioning in chronic stroke patients. Protocols for exercise testing and longitudinal aerobic training progression are presented that provide fundamental formulas that safely approach the complex task of customizing aerobic training to gait deficit severity in the high CVD risk stroke population. The beneficial effects of 6 months task-oriented treadmill exercise on cardiovascular-metabolic fitness, energy cost of hemiparetic gait, ADL mobility task performance, and leg strength are discussed with respect to the central and peripheral neuromuscular adaptations targeted by the training. Collectively, these findings constitute one initial experience in a much broader neuroscience and exercise rehabilitation development of task-oriented training paradigms that offer a multisystems approach to improving both neurological and cardiovascular health outcomes in the chronic stroke population.

Impact of serum nutritional status on physical function in african american and caucasian stroke survivors

Background. The purpose of this study is to compare serum nutritional profiles in chronic stroke survivors to a representative sample of US Adults (NHANESIII) and determine whether these serum markers differed by race and impact physical function in stroke. Methods. Fasting serum samples were collected for analysis of lipids, uric acid, and albumin in 145 African American (AA) and 111 Caucasian (C) stroke survivors (age: 60 ± 1 years [mean ± SEM]). A six-minute walk was performed in a subset of stroke survivors (N = 134). Results. Triglycerides were higher and HDL-cholesterol and albumin lower in C than AA women stroke survivors (Ps < 0.05). Uric acid was lower in C than AA stroke survivors (P < 0.05). Compared to NHANESIII, HDL-cholesterol, albumin, and hemoglobin generally were lower (Ps < 0.05) and lipids were more favorable in stroke (Ps < 0.01). Uric acid was related to six-minute walk performance among a subset of stroke survivors (P < 0.05). Conclusion. In stroke, racial differences exist with regard to serum nutritional risk, but these differences are similar to that observed in the general population. Regardless of race, nutritional risk appears elevated above that of the general population with regard to many of the serum markers. As a modifiable biomarker, uric acid should be monitored closely as it may provide insight into the functional risk of stroke survivors.

High-intensity interval training in stroke rehabilitation

After stroke, people with weakness enter a vicious cycle of limited activity and deconditioning that limits functional recovery and exacerbates cardiovascular risk factors. Conventional aerobic exercise improves aerobic capacity, function, and overall cardiometabolic health after stroke. Recently, a new exercise strategy has shown greater effectiveness than conventional aerobic exercise for improving aerobic capacity and other outcomes among healthy adults and people with heart disease. This strategy, called high-intensity interval training (HIT), uses bursts of concentrated effort alternated with recovery periods to maximize exercise intensity. Three poststroke HIT studies have shown preliminary effectiveness for improving functional recovery. However, these studies were varied in approach and the safety of poststroke HIT has received little attention. The objectives of this narrative review are to (1) propose a framework for categorizing HIT protocols; (2) summarize the safety and effectiveness evidence of HIT among healthy adults and people with heart disease and stroke; (3) discuss theoretical mechanisms, protocol selection, and safety considerations for poststroke HIT; and (4) provide directions for future research.

[Eccentric exercise as preventive physical option in people over 65 years: a systematic review of the scientific literature]

OBJECTIVE

To review the scientific literature to determine t the benefits eccentric exercise for people over 65, and how to apply this.

METHOD

A systematic documental study was made of randomized clinical trials published in journals indexed in international databases, excluding those that were not based on the target population (over 65 years) and/or used drugs in the intervention.

RESULTS

A total of 10 articles were selected for review from the following countries of origin: Switzerland, United States, Canada and United Kingdom. Some were based on a healthy population, with others on cardiovascular, musculoskeletal, and Parkinson's disease and hemiparesis. Eccentric exercise was performed using, cyclo-ergometer, knee exercise with dynamometer, treadmill, and exercises with machines.

CONCLUSIONS

Eccentric training is an option to reduce and prevent sarcopenia. Due to its low metabolic cost and reduced oxygen consumption it is optimal in cardiovascular disorders, chronic illness and frailty. It decreases risk of falling, and improves mobility and quality of life. The bicycle and treadmill movements, aimed at specific segments, with or without load, and downhill walking are low cost resources that can be used. More research studies are required on this theme, with increased population sizes, as well as studies including interventions for upper body segments.

Randomized Trial of Treadmill Training to Improve Walking in Community-Dwelling People after Stroke: The AMBULATE Trial

Background

Residual walking deficits are common in community-dwelling people after stroke.

Aims

The aim of this study was to determine if a four-month treadmill and overground walking program is more effective than a two-month program, compared with control, at improving walking in community-dwelling people with stroke who walk slowly.

Method

A three-arm randomized trial with concealed allocation, assessor blinding, and intention-to-treat analysis involving 102 people with stroke living in the community who walked slowly was undertaken. Experimental group 1 undertook 30 min of treadmill and overground walking thrice per week for four-months, experimental group 2 undertook training for two-months, while the control group had no intervention. The primary outcome was walking measured as the distance covered during the six-min walk test. Other outcomes were walking speed, step length and cadence, health status, community participation, self-efficacy and falls.

Results

By two-months, the experimental groups, who were both undergoing training, had improved their six-min walk distance compared with the control group. The four-month training group continued training beyond two-months and improved further so that by four months they walked 38 m (95% confidence interval 15–60) more than the control group and 29 m (95% confidence interval 4–53) more than the two-month training group. However, by 12 months, well after the cessation of training, both experimental groups had returned to near baseline levels, and there was no difference between the groups.

Conclusion

Four months of treadmill training results in better walking. However, these effects disappear once training ceases. Therefore, training should be ongoing.

A randomized comparative study of manually assisted versus robotic-assisted body weight supported treadmill training in persons with a traumatic brain injury

OBJECTIVES

(1) To compare the effects of robotic-assisted treadmill training (RATT) and manually assisted treadmill training (MATT) in participants with traumatic brain injury (TBI) and (2) to determine the potential impact on the symmetry of temporal walking parameters, 6-minute walk test, and the mobility domain of the Stroke Impact Scale, version 3.0 (SIS).

DESIGN

Randomized prospective study.

SUBJECTS

A total of 16 participants with TBI and a baseline over ground walking self-selected velocity (SSV) of ≥0.2 m/s to 0.6 m/s randomly assigned to either the RATT or MATT group.

INTERVENTION

Gait training for 45 minutes, 3 times a week with either RATT or MATT for a total of 18 training sessions.

OUTCOME MEASURES

Primary: Overground walking SSV, maximal velocity. Secondary: Spatiotemporal symmetry, 6-minute walk test, and SIS.

RESULTS

Between-group differences were not statistically significant for any measure. However, from pretraining to post-training, the average SSV increased by 49.8% for the RATT group (P = .01) and by 31% for MATT group (P = .06). The average maximal velocity increased by 14.9% for the RATT group (P = .06) and by 30.8% for the MATT group (P = .01). Less staffing and effort was needed for RATT in this study. Step-length asymmetry ratio improved during SSV by 33.1% for the RATT group (P = .01) and by 9.1% for the MATT group (P = .73). The distance walked increased by 11.7% for the robotic group (P = .21) and by 19.3% for manual group (P = .03). A statistically significant improvement in the mobility domain of the SIS was found for both groups (P ≤ .03).

CONCLUSIONS

The results of this study demonstrate greater improvement in symmetry of gait (step length) for RATT and no significant differences between RATT and MATT with regard to improvement in gait velocity, endurance, and SIS. Our study provides evidence that participants with a chronic TBI can experience improvements in gait parameters with gait training with either MATT or RATT.

Changes in fat mass in stroke survivors: a systematic review

BACKGROUND

Stroke survivors have less muscle mass in their paretic limbs compared with nonparetic limbs, which may or may not be accompanied by changes in regional and/or whole body fat mass.

AIM

To examine the current evidence regarding differences in regional fat mass between paretic and nonparetic limbs and changes in whole body fat mass over time in stroke survivors.

METHODS

A systematic search of relevant databases. Studies measuring whole body or regional fat mass using dual-energy X-ray absorpiometry, computed tomography, or magnetic resonance imaging were included.

RESULTS

Eleven trials were identified. Fat mass differences between paretic and nonparetic limbs and change in fat mass over time were not consistent. Meta-analyses were conducted using dual-energy X-ray absorpiometry-derived data from 10 trials (n = 324). There were no differences in fat mass between paretic and nonparetic legs (pooled mean difference 31·4 g, 95% confidence interval -33·9 to 96·6, P = 0·35), and slightly greater fat mass in the paretic arms compared with nonparetic arms (pooled mean difference 84·0 g, 95% confidence interval 30·7 to 137·3, P = 0·002). Whole body fat mass did not increase significantly between one-month and six-months poststroke (pooled mean difference 282·3 g, 95% confidence interval -824·4 to 1389, P = 0·62), but there was an increase between six- and 12 months poststroke (pooled mean difference 1935 g, 95% confidence interval 1031 to 2839, P < 0·001).

CONCLUSIONS

There were inconsistent findings regarding changes in fat mass after stroke. Large, well-designed studies are required to further investigate the impact of body composition changes on the health of stroke survivors.

Impact of treadmill exercise on efficacy expectations, physical activity, and stroke recovery

Stroke survivors are at high risk for cardiovascular mortality which can be in part mitigated by increasing physical activity. Self-efficacy for exercise is known to play a role in adoption of exercise behaviors. This study examines self-reported psychological outcomes in a group of 64 stroke survivors randomized to either a 6-month treadmill training program or a stretching program. Results indicated that, regardless of group, all study participants experienced increased self-efficacy (F = 2.95, p = .09) and outcome expectations for exercise (F = 13.23, p < 0.001) and improvements in activities of daily living as reported on the Stroke Impact Scale (F = 10.97, p = .002). No statistically significant between-group differences were noted, possibly because of the fact that specific interventions designed to enhance efficacy beliefs were not part of the study. Theoretically based interventions should be tested to clarify the role of motivation and potential influence on exercise and physical activity in the stroke survivor population.

Intensive aerobic cycling training with lower limb weights in Chinese patients with chronic stroke: discordance between improved cardiovascular fitness and walking ability

PURPOSE

To evaluate the effect of aerobic cycling training with lower limb weights on cardiovascular fitness (peak VO(2)) and walking ability in chronic stroke survivors, and to investigate the relationship between changes in these parameters.

METHODS

133 Chinese patients with chronic hemiparetic stroke (mean age 58 years) were randomized to either 8-week (5×/week) aerobic cycling training with lower limb weights group (n = 68) or a low-intensity overground walking group (n = 65). Peak VO(2), 6-minute walk distance (6MWD), knee muscle strength, balance and spasticity were measured before and after intervention.

RESULTS

Cycling training increased peak VO(2) (24% vs. 3%, p < 0.001), 6MWD (2.7% vs. 0.5%, p < 0.001), paretic (11% vs. 1.6%, p < 0.001) and nonparetic knee strength (16% vs. 1.0%, p < 0.001). In the cycling group, percent changes in peak VO(2) were positively associated with those in paretic (r = 0.491, p < 0.001) and nonparetic knee strength (r = 0.432, p < 0.001). Increased 6MWD correlated significantly with improved balance, spasticity and paretic knee strength by the stepwise regression analysis (r(2) = 0.342, p = 0.004), but not fitness gains.

CONCLUSIONS

The enhanced cardiovascular fitness after aerobic cycling training in Chinese patients with chronic stroke is not associated with the increased walking ability. Unparallel improvements in these parameters related different determinants may have implications for intervention strategy.

Impact of exercise to improve gait efficiency on activity and participation in older adults with mobility limitations: a randomized controlled trial

BACKGROUND

Definitive evidence that exercise interventions that improve gait also reduce disability is lacking. A task-oriented, motor sequence learning exercise intervention has been shown to reduce the energy cost of walking and improve gait speed, but whether the intervention also improves activity and participation has not been demonstrated.

OBJECTIVE

The objective of this study was to compare the impact of a task-oriented, motor sequence learning exercise (TO) intervention and the impact of an impairment-oriented, multicomponent exercise (IO) intervention on activity and participation outcomes in older adults with mobility limitations. The mediating effects of a change in the energy cost of walking on changes in activity and participation also were determined.

DESIGN

This study was a single-blind, randomized controlled trial. Setting The study was conducted in an ambulatory clinical research training center.

PARTICIPANTS

The study participants were 47 older adults (mean age=77.2 years, SD=5.5) with slow and variable gait. Intervention The intervention was a 12-week, physical therapist-guided program of TO or IO.

MEASUREMENTS

Measures of activity (gait speed over an instrumented walkway; daily physical activity measured with an accelerometer; confidence in walking determined with the Gait Efficacy Scale; and physical function determined with the total, basic lower-extremity, and advanced lower-extremity components of the Late-Life Function and Disability Instrument [Late-Life FDI]) and participation (disability limitation dimension and instrumental role [home and community task performance] domain components of the Late-Life FDI) were recorded before and after the intervention. The energy cost of walking was determined from the rate of oxygen consumption during self-paced treadmill walking at the physiological steady state standardized by walking speed. An adjusted comparison of activity and participation outcomes in the treatment arms was made by use of an analysis of covariance model, with baseline and change in energy cost of walking added to the model to test for mediation. Tests were used to determine the significance of the mediating effects.

RESULTS

Activity improved in TO but not in IO for confidence in walking (Gait Efficacy Scale; mean adjusted difference=9.8 [SD=3.5]) and physical function (Late-Life FDI basic lower-extremity component; mean adjusted difference=3.5 [SD=1.7]). Improvements in TO were marginally greater than those in IO for gait speed, physical activity, and total physical function. Participation improved marginally more in TO than in IO for disability limitations and instrumental role.

LIMITATIONS

The older adults were randomized to the intervention group, but differences in baseline measures had to be accounted for in the analyses.

CONCLUSIONS

A TO intervention that improved gait also led to improvements in some activity and participation outcomes in older adults with mobility limitations.

Exercise intervention research in stroke: optimizing outcomes through treatment fidelity

BACKGROUND

Demonstrating the treatment fidelity of an intervention is a key methodological requirement of any trial testing the impact of the intervention.

PURPOSE

The purpose of this report was to serve as a model for evaluating treatment fidelity in stroke exercise intervention studies and to provide evidence for treatment fidelity in the Exercise Training for Hemiparetic Stroke Intervention Development Study.

METHODS

Treatment fidelity was evaluated based on study design, training of interventionists, and delivery and receipt of the intervention.

RESULTS

There were some concerns about design fidelity as the control group and intervention group traveled to the study location together and received different exercise programs in the same facility. With regard to training of interventionists, observations were utilized to help maintain adherence to the protocol. There was strong support for the delivery and receipt of the intervention with participants exposed to the anticipated number of exercise sessions. As per study protocol, there was evidence that progress toward the proposed physical activity goal was made. Treatment fidelity findings are reported using cumulative data rather than at points throughout the study. Thus the findings may be conservative with regard adherence, for example, to time spent in exercise.

CONCLUSION

In addition to assurance of true testing of the intervention in this study, treatment fidelity of this work provides a useful model for replication and critically important information to better understand the type, dose, and length of exposure to exercise interventions that is needed to optimize stroke recovery.

Effects of high-intensity resistance training on strength, mobility, balance, and fatigue in individuals with multiple sclerosis: a randomized controlled trial

BACKGROUND AND PURPOSE

Resistance exercise via negative, eccentrically induced work (RENEW) has been shown to be associated with improvements in strength, mobility, and balance in multiple clinical populations. However, RENEW has not been reported for individuals with multiple sclerosis (MS).

METHODS

Nineteen individuals with MS (8 men, 11 women; age mean = 49 ± 11 years; Expanded Disability Status Scale [EDSS] mean = 5.2 ± 0.9) were randomized into either standard exercise (STAND) or standard exercise and RENEW training (RENEW) for 3×/week for 12 weeks. Outcome measures were lower extremity strength (hip/knee flexion and extension, ankle plantar and dorsiflexion, and the sum of these individual values [sum strength]); Timed Up and Go (TUG), 10-m walk, self-selected pace (TMWSS) and maximal-pace (TMWMP), stair ascent (S-A) and descent (S-D) and 6-Minute Walk Test (6MWT), Berg Balance Scale (BBS), Fatigue Severity Scale (FSS).

RESULTS

No significant time effects or interactions were observed for strength, TUG, TMWSS, TMWMP, or 6MWT. However, the mean difference in sum strength in the RENEW group was 38.60 (representing a 15% increase) compared to the sum strength observed in the STAND group with a mean difference of 5.58 (a 2% increase). A significant interaction was observed for S-A, S-D, and BBS as the STAND group improved whereas the RENEW group did not improve in these measures.

DISCUSSION AND CONCLUSIONS

Contrary to results in other populations, the addition of eccentric training to standard exercises did not result in significantly greater lower extremity strength gains in this group of individuals with MS. Further this training was not as effective as standard exercise alone in improving balance or the ability to ascend and descend stairs. Following data collection, reassessment of required sample size indicates we were likely underpowered to detect strength differences between groups.

Effect of early compensation of distal motor deficiency by the Chignon ankle-foot orthosis on gait in hemiplegic patients: a randomized pilot study

Objective: To compare the effect of the Chignon ankle-foot orthosis on gait versus a standard ankle-foot orthosis.

Method: A multicentre randomized study was conducted in seven rehabilitation centres. Hemiplegic patients were recruited after unilateral stroke lasting less than six months. Exclusion criteria were: impossibility to stand for 10 seconds; ankle passive dorsiflexion <5 degrees with knee flexed to 90 degrees; triceps spasticity ≥3/4 on the Ashworth modified scale; diseases that might impair active participation in the study. Thirteen patients were randomized to the Chignon group and 15 to the control group. Included patients were given a standard ankle-foot orthosis or Chignon ankle-foot orthosis. The Chignon ankle-foot orthosis is an articulated double-stopped custom-made orthosis with elements to assist dorsiflexion and plantar flexion. Gait speed improvement (ten-metre test), kinematic assessment, and functional scales were assessed.

Results: Gain ratio of walking speed with the orthosis increased significantly more in the Chignon group than in the control group at day 0 (27.2  ±  36% versus −0.8  ±  17%; P = 0.006), day 30 (39.9  ±  19% versus 7.5  ±  17%; P = 0.0004) and day 90 (44.6  ±  27% versus 17.1  ±  0.3%; P = 0.04). There was also a significant improvement in kinematic parameters and spasticity in the Chignon group.

Conclusion: Early compensation of distal motor deficiency by the Chignon ankle-foot orthosis improves the immediate gait of hemiplegics more than the standard ankle-foot orthosis and seems to modify motor recovery processes in the legs after stroke.

Rehabilitation of gait speed after stroke: a critical review of intervention approaches

PURPOSE

Walking speed is a cardinal indicator of poststroke gait performance; however, no consensus exists regarding the optimal treatment method(s) for its enhancement. The most widely accepted criterion for establishing the contribution of treatment to walking speed is the gain in speed. The actual speed, however, at the end of the intervention (final speed) may be more important for functional community ambulation. This review examines the contribution of the prevailing methods for gait rehabilitation to final walking speed.

METHOD

Walking speed information was derived from studies included in meta-analyses, systematic reviews, and clinical practice guidelines. Recent references, not included in the mentioned sources, were incorporated in cases when gait speed was an outcome variable. Final speed was assessed by the reported speed values and by inferring the capacity for functional community walking at the end of the intervention period.

RESULTS

Similar outcomes for final walking speed were found for the different prevailing treatment methods. Treatment gains were likewise comparable and generally insufficient for upgrading patients' functional community walking capacity.

CONCLUSIONS

Different treatment methods exist for poststroke gait rehabilitation. Their availability, mode of application, and costs vary, yet outcomes are largely similar. Therefore, choosing an appropriate method may be guided by a pragmatic approach. Simple "low technology" and conventional exercise to date is at least as efficacious as more complex strategies such as treadmill and robotic-based interventions.

Reducing the energy cost of hemiparetic gait using center of mass feedback: a pilot study

BACKGROUND

Hemiparetic gait following stroke requires substantial energy consumption, which would promote deconditioning and disability. Optimal modalities for decreasing this energy cost remain challenging. Excessive energy consumption, however, seems to be mainly due to extra positive muscle work to substantially lift the body's center of mass (CM) against gravity during the paretic limb swing.

OBJECTIVE

The authors tested a new rehabilitation strategy in a pilot study to specifically reduce the energy cost in hemiparetic gait.

METHODS

Six chronic hemiparetic patients underwent a 6-week gait training program on a treadmill with real-time feedback of their CM and were asked to reduce its increased vertical displacement. The authors assessed the walking energy cost, vertical CM displacement, kinematics, and electromyogram activity without feedback before and after treatment.

RESULTS

After treatment, the vertical CM displacement decreased by 10% (P = .005), particularly when the CM vaulted over the nonparetic limb in stance, and the energy cost decreased markedly by 30% (P = .009). The paretic knee flexion in swing increased concomitantly by 45% and muscle co-contraction decreased significantly in both thigh muscles by 15%.

CONCLUSIONS

The rehabilitation approach followed in this study seems remarkably effective in decreasing the walking energy cost. By treating the compensatory strategy (ie, the increased CM displacement), we also appear to treat primary deviations such as poststroke knee impairments, which is novel and complementary to current concepts in rehabilitation. This new approach is promising and merits further investigation.

Hemiparetic stroke alters vastus lateralis myosin heavy chain profiles between the paretic and nonparetic muscles

Skeletal muscle phenotype alterations following hemiparetic stroke contribute to disabilities associated with stroke. The phenotypic response following stroke is undefined. This investigation examined the myosin heavy chain (MHC) composition of the vastus lateralis (VL) of stroke survivors in paretic (P) and nonparetic (NP) muscle. Protein obtained from VL of 10 stroke survivors was isolated and purified, and MHC gel electrophoresis was performed. The MHC bands were quantified, and a paired sample two-tailed T test with significance set at p < or = 0.05 was performed. MHC I expression was significantly less in P versus NP VL (.93 vs. 1.00 arbitrary units [AU]). Significantly more IIx MHC was found in the P versus NP VL (1.33 vs. 1.0). No significant differences in type IIa MHC (1.07 P vs. 1.00 NP) were found. These changes in MHC composition suggest an alteration in muscle function due to stroke or the altered activity patterns of muscle following stroke.

Rapid and long-term adaptations in gait symmetry following unilateral step training in people with hemiparesis

BACKGROUND AND OBJECTIVE

Evidence for specific physical interventions that improve walking symmetry in individuals with hemiparesis poststroke is limited. The aim of this study was to investigate the rapid and prolonged effects of unilateral step training (UST) on step length asymmetry (SLA) in people with hemiparesis.

SUBJECTS AND DESIGN

Eighteen individuals with chronic hemiparesis and substantial SLA during overground walking participated in a single-group, pretest-posttest study. The study consisted of 2 phases, with 10 subjects participating in each phase; 2 subjects participated in both phases.

INTERVENTIONS AND MEASUREMENTS

To investigate rapid effects of UST, the participants completed a 20-minute session of UST on a treadmill with their unimpaired limb, with the impaired limb held stationary off the treadmill. Data for spatiotemporal gait parameters during overground walking at self-selected and fastest speeds were collected prior to and following UST, with follow-up measurements at 1 day and 1 week. To investigate the prolonged effects, the participants completed ten 20-minute sessions of UST. Data for spatiotemporal gait parameters were collected prior to training as well as after every third session, with follow-up measurements at 1 and 2 weeks.

RESULTS

Immediately following UST, SLA tested during fast-paced overground walking improved by up to 13% (49% reduced to a 36% SLA), with changes retained for up to 24 hours. Following 10 sessions of UST, SLA improved significantly, with changes retained for up to 2 weeks.

LIMITATIONS

Despite repeated baseline measurements, the absence of a control group was a limitation. Furthermore, stepping characteristics during UST were not quantified.

CONCLUSION

Unilateral step training may improve spatiotemporal patterns in people with substantial gait asymmetry poststroke. Repeated training may be necessary for maintenance of adaptations.

Task-oriented treadmill exercise training in chronic hemiparetic stroke

Patients with stroke have elevated hemiparetic gait costs secondary to low activity levels and are often severely deconditioned. Decrements in peak aerobic capacity affect functional ability and cardiovascular-metabolic health and may be partially mediated by molecular changes in hemiparetic skeletal muscle. Conventional rehabilitation is time delimited in the subacute stroke phase and does not provide adequate aerobic intensity to reverse the profound detriments to fitness and function that result from stroke. Hence, we have studied progressive full body weight-support treadmill (TM) training as an adjunct therapy in the chronic stroke phase. Task-oriented TM training has produced measurable changes in fitness, function, and indices of cardiovascular-metabolic health after stroke, but the precise mechanisms for these changes remain under investigation. Further, the optimal dose of this therapy has yet to be identified for individuals with stroke and may vary as a function of deficit severity and outcome goals. This article summarizes the functional and metabolic decline caused by inactivity after stroke and provides current evidence that supports the use of TM training during the chronic stroke phase, with protocols and inclusion/exclusion criteria described. Our research findings are discussed in relation to associated research.

Improving community ambulation after stroke: the AMBULATE Trial

Background

It has been reported that following rehabilitation, only 7% of stroke survivors are able to walk at a level commensurate with community participation. Previous research indicates that treadmill and overground walking training can improve walking capacity in people living in the community after stroke. The main objectives of the AMBULATE trial are to determine (i) whether a 4-month treadmill walking program is more effective than a 2-month program, compared to control, in improving walking capacity, health and community participation and (ii) the "threshold" walking speed that results in sufficient walking capacity that makes walking self-sustaining.

Methods/Design

A prospective randomised controlled trial of unsupported treadmill training with a 12 month follow-up with concealed allocation and blinded assessment will be conducted. 210 community-dwelling people after stroke who are able to walk independently but slowly will be recruited and randomly allocated to either a 4 month training group, 2 month training group or the control (no intervention) group. Intervention for the two training groups will occur 3 days per week for 30 minutes each session. Measurements of walking, health and community participation will be taken at baseline, 2 months, 4 months, 6 months and 12 months. This study has obtained ethical approval from the relevant Human Research Ethics Committees.

Discussion

By improving stroke survivors' walking ability, it is likely also to improve their general wellbeing by promoting better health and greater community participation. Furthermore, if stroke survivors can reach a point where their walking and community participation is self-sustaining, this will reduce the burden of care on family and friends as well as the economic burden on the health system. Given the major demographic shift in developed nations involving significant growth in the aged population, this research will make an important evidence-based contribution to the promotion of healthy ageing.

Trial registration

This trial is registered with the Australian New Zealand Clinical Trials Registry, (ACTRN012607000227493)

Activity-based electrical stimulation training in a stroke patient with minimal movement in the paretic upper extremity

BACKGROUND

Existing task-specific practice interventions do not increase movement in stroke patients exhibiting minimal distal movement in the paretic upper extremity. Although often used, an important limitation of conventional electrical stimulation is that it does not involve task-specific practice.

OBJECTIVE

To determine the impact of an activity-specific electrical stimulation program on paretic limb impairment, functional limitation, and ability to perform valued activities in a subacute stroke patient exhibiting minimal paretic wrist and hand movement.

METHOD

A female subject exhibiting trace paretic hand and finger movement was administered, 9 months after stroke, the upper extremity section of the Fugl-Meyer Impairment Scale (FM), the Action Research Arm Test (ARAT), and the Arm Motor Ability Test (AMAT). She then engaged in paretic upper extremity, task-specific training incorporating an electrical stimulation neuroprosthesis. Training occurred 3 hours per day, 5 days per week for 3 weeks. The FM, ARAT, and AMAT were again administered.

RESULTS

After intervention, she exhibited reduced impairment (evidenced by an FM score change of 22 to 29), decreased functional limitation (evidenced by an ARAT score change of 4 to 10), and increased ability and speed in performing valued AMAT activities. She also reported using the paretic hand and fingers more and new abilities to perform valued activities such as playing piano.

CONCLUSION

Although conventional paretic upper extremity training strategies are ineffective in patients at this level, electrical stimulation training incorporating a neuroprosthesis appears promising.

The effect of aquatic therapy on postural balance and muscle strength in stroke survivors — a randomized controlled pilot trial

Objective: To evaluate the effect of an aquatic therapy programme designed to increase balance in stroke survivors.

Design: A randomized, controlled pilot trial.

Setting: Rehabilitation department of a university hospital.

Subjects: Ambulatory chronic stroke patients (n = 25):13 in an aquatic therapy group and 12 in a conventional therapy group.

Interventions: The aquatic therapy group participated in a programme consisting of Ai Chi and Halliwick methods, which focused on balance and weight-bearing exercises. The conventional therapy group performed gym exercises. In both groups, the interventions occurred for 1 hour, three times per week, for eight weeks.

Main measures: The primary outcome measures were Berg Balance Scale score and weight-bearing ability, as measured by vertical ground reaction force during four standing tasks (rising from a chair and weight-shifting forward, backward and laterally). Secondary measures were muscle strength and gait.

Results: Compared with the conventional therapy group, the aquatic therapy group attained significant improvements in Berg Balance Scale scores, forward and backward weight-bearing abilities of the affected limbs, and knee flexor strength (P<0.05), with effect sizes of 1.03, 1.14, 0.72 and 1.13 standard deviation units and powers of 75, 81, 70 and 26%, respectively. There were no significant changes in the other measures between the two groups.

Conclusions: Postural balance and knee flexor strength were improved after aquatic therapy based on the Halliwick and Ai Chi methods in stroke survivors. Because of limited power and a small population base, further studies with larger sample sizes are required.

Resistance-based, reciprocal upper and lower limb locomotor training in chronic stroke: a randomized, controlled crossover study

Objective: To determine efficacy of a bilateral reciprocal training regimen on affected leg impairment and dynamic balance.

Design: Randomized, controlled, single-blinded crossover study.

Setting: Outpatient rehabilitation hospital.

Participants: Seven patients who experienced stroke >1 year prior to study entry exhibiting affected leg weakness.

Intervention: Subjects were randomly assigned to receive both of the following in a randomized, sequential order: (a) a resistance-based, reciprocal, affected leg locomotor training protocol using the NuStep apparatus ( n = 4) and (b) a home exercise programme (HEP) consisting of self-supervised practice with fractionated joint movements of the lower limb. Each phase of the intervention was performed for 30 minutes each session, three days a week, and conducted over an eight-week period.

Main outcome measures: Outcomes were evaluated by a blinded rater using the lower extremity scale of the Fugl-Meyer and the Berg Balance Scale.

Results: After HEP participation, subjects showed nominal or no changes on any of the outcome measures. After NuStep participation, patients in both treatment groups showed impairment reductions as shown by the Fugl-Meyer (+4.3; +2.2), and increased balance as shown by the Berg Balance Scale (+4.0; +4.0). These trends were exhibited regardless of group assignment.

Conclusion: Impairment reductions and balance gains may be achieved using a resistance-based, reciprocal upper and lower limb locomotor training protocol.

Skeletal muscle changes after hemiparetic stroke and potential beneficial effects of exercise intervention strategies

Stroke is the leading cause of disability in the United States. New evidence reveals significant structural and metabolic changes in skeletal muscle after stroke. Muscle alterations include gross atrophy and shift to fast myosin heavy chain in the hemiparetic (contralateral) leg muscle; both are related to gait deficit severity. The underlying molecular mechanisms of this atrophy and muscle phenotype shift are not known. Inflammatory markers are also present in contralateral leg muscle after stroke. Individuals with stroke have a high prevalence of insulin resistance and diabetes. Skeletal muscle is a major site for insulin-glucose metabolism. Increasing evidence suggests that inflammatory pathway activation and oxidative injury could lead to wasting, altered function, and impaired insulin action in skeletal muscle. The health benefits of exercise in disabled populations have now been recognized. Aerobic exercise improves fitness, strength, and ambulatory performance in subjects with chronic stroke. Therapeutic exercise may modify or reverse skeletal muscle abnormalities.