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Lyu T, Yan K, Lyu J, Zhao X, Wang R, Zhang C, Liu M, Xiong C, Liu C, Wei Y. Comparative efficacy of gait training for balance outcomes in patients with stroke: A systematic review and network meta-analysis. Front Neurol 2023; 14:1093779. [PMID: 37077566 PMCID: PMC10106590 DOI: 10.3389/fneur.2023.1093779] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/01/2023] [Indexed: 04/05/2023] Open
Abstract
BackgroundGrowing evidence suggests that gait training can improve stroke patients’ balance outcomes. However, it remains unclear which type of gait training is more effective in improving certain types of balance outcomes in patients with stroke. Thus, this network meta-analysis (NMA) included six types of gait training (treadmill, body-weight-supported treadmill, virtual reality gait training, robotic-assisted gait training, overground walking training, and conventional gait training) and four types of balance outcomes (static steady-state balance, dynamic steady-state balance, proactive balance, and balance test batteries), aiming to compare the efficacy of different gait training on specific types of balance outcomes in stroke patients and determine the most effective gait training.MethodWe searched PubMed, Embase, Medline, Web of Science, and Cochrane Library databases from inception until 25 April 2022. Randomized controlled trials (RCTs) of gait training for the treatment of balance outcomes after stroke were included. RoB2 was used to assess the risk of bias in the included studies. Frequentist random-effects network meta-analysis (NMA) was used to evaluate the effect of gait training on four categories of balance outcomes.ResultA total of 61 RCTs from 2,551 citations, encompassing 2,328 stroke patients, were included in this study. Pooled results showed that body-weight-support treadmill (SMD = 0.30, 95% CI [0.01, 0.58]) and treadmill (SMD = 0.25, 95% CI [0.00, 0.49]) could improve the dynamic steady-state balance. Virtual reality gait training (SMD = 0.41, 95% CI [0.10, 0.71]) and body-weight-supported treadmill (SMD = 0.41, 95% CI [0.02, 0.80]) demonstrated better effects in improving balance test batteries. However, none of included gait training showed a significant effect on static steady-state balance and proactive balance.ConclusionGait training is an effective treatment for improving stroke patients’ dynamic steady-state balance and balance test batteries. However, gait training had no significant effect on static steady-state balance and proactive balance. To achieve maximum efficacy, clinicians should consider this evidence when recommending rehabilitation training to stroke patients. Considering body-weight-supported treadmill is not common for chronic stroke patients in clinical practice, the treadmill is recommended for those who want to improve dynamic steady-state balance, and virtual reality gait training is recommended for those who want to improve balance test batteries.LimitationMissing evidence in relation to some types of gait training is supposed to be taken into consideration. Moreover, we fail to assess reactive balance in this NMA since few included trials reported this outcome.Systematic Review RegistrationPROSPERO, identifier CRD42022349965.
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Affiliation(s)
- Tianyi Lyu
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Kang Yan
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Jiaxuan Lyu
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Xirui Zhao
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Ruoshui Wang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Chaoyang Zhang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Meng Liu
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Chao Xiong
- L3 & Maintenance Solutions, SUSE Software (Beijing) Co., Ltd., Beijing, China
| | - Chengjiang Liu
- Department of General Medicine, Affiliated Anqing First People’s Hospital of Anhui Medical University, HeFei, Anhui, China
| | - Yulong Wei
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
- *Correspondence: Yulong Wei,
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Usman JS, Gbiri CAO, Olawale OA. Predictors of ambulatory recovery and walking proficiency in community-dwelling stroke survivors: a cross-sectional study. BULLETIN OF FACULTY OF PHYSICAL THERAPY 2022. [DOI: 10.1186/s43161-022-00097-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Although the major goal of rehabilitation is to return a stroke survivor (SSv) to as close to their pre-stroke functioning, limitation in ambulatory recovery and walking proficiency is the major impediment. Despite the importance of walking to the outcomes in stroke, factors predicting its recovery remain unclear. This study therefore was aimed at exploring the predictors of ambulatory recovery and walking proficiency in community-dwelling SSv.
Methods
This study involved 164 (83females) SSv from four tertiary health institutions in Nigeria. Ambulatory level and status was assessed using Functional Ambulatory Classification, motor function using the Fugl-Myer Assessment scale (lower limb), and ambulatory/waking endurance using the 6-min walk test. Ambulatory capability was assessed using the Lower Extremity Functional Scale, ambulatory self-confidence using the Ambulatory Self-Confidence Questionnaire, and functional ambulatory profile using the Modified Emory Functional Ambulation Profile. Mobility was assessed using the Modified Rivermead Mobility Index, functional mobility using Time Up and Go, balance using the Berg Balance Scale, and cognitive function using the modified Mini-Mental State Examination. Spatial indexes were assessed using the Footprint method and temporal variables using a stopwatch and gait speed on a 10-m walkway. Data was analyzed using multiple regression analysis at p ≤ 0.05.
Results
Participants (mean age = 54.3±11.36 years) have had stroke for 12.9 ± 17.39 months and spent 9.82 ± 13.19 months in hospital admissions. More (65.2%) had ischemic stroke with 54.3% of them having left hemispheric stroke. The predictors of ambulatory onset in SSv were stroke duration and length of stay in hospital admission contributing 40.3% (β = 0.403) and 17.6% (β = 0.176) respectively to the variance. Mobility (β = 0.249, p < 0.001), gait speed (β = 0.185, p = 0.012), paretic double-limb support time (β = 0.155, p = 0.03), balance (β = 0.334, p < 0.001), and cognition (β = 0.155, p = 0.01) were predictors of ambulatory self-confidence contributing 59.5% to the variance. Balance (β = 0.363, p < 0.001) and mobility (β = 0.155, p = 0.015) were predictors of ambulatory capability contributing 52.9% to the variance. Balance (β = −0.489, p < 0.001), paretic double-limb support time (β = 0.223, p = 0.003), gait speed (β = −0.181, p = 0.022), and paretic swing phase duration (β = 0.177, p = 0.01) were predictors of functional ambulatory profile (p < 0.05) contributing 52.9% to the variance. Gait speed (β = −0.648, p < 0.001) and step length (β = −0.157, p = 0.003) were predictors of walking endurance contributing 76.5% to the variance.
Conclusion
Ambulatory recovery and walking proficiency depend on the interplay among duration of stroke and length of hospitalization on the one hand and balance performance, cognitive function, and the spatiotemporal integrity of the affected limb on the other hand.
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Marzolini S, Wu C, Hussein R, Xiong LY, Kangatharan S, Peni A, Cooper CR, Lau KS, Nzodjou Makhdoom G, Pakosh M, Zaban SA, Nguyen MM, Banihashemi MA, Swardfager W. Associations Between Time After Stroke and Exercise Training Outcomes: A Meta-Regression Analysis. J Am Heart Assoc 2021; 10:e022588. [PMID: 34913357 PMCID: PMC9075264 DOI: 10.1161/jaha.121.022588] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Knowledge gaps exist regarding the effect of time elapsed after stroke on the effectiveness of exercise training interventions, offering incomplete guidance to clinicians. Methods and Results To determine the associations between time after stroke and 6-minute walk distance, 10-meter walk time, cardiorespiratory fitness and balance (Berg Balance Scale score [BBS]) in exercise training interventions, relevant studies in post-stroke populations were identified by systematic review. Time after stroke as continuous or dichotomized (≤3 months versus >3 months, and ≤6 months versus >6 months) variables and weighted mean differences in postintervention outcomes were examined in meta-regression analyses adjusted for study baseline mean values (pre-post comparisons) or baseline mean values and baseline control-intervention differences (controlled comparisons). Secondary models were adjusted additionally for mean age, sex, and aerobic exercise intensity, dose, and modality. We included 148 studies. Earlier exercise training initiation was associated with larger pre-post differences in mobility; studies initiated ≤3 months versus >3 months after stroke were associated with larger differences (weighted mean differences [95% confidence interval]) in 6-minute walk distance (36.3 meters; 95% CI, 14.2-58.5), comfortable 10-meter walk time (0.13 m/s; 95% CI, 0.06-0.19) and fast 10-meter walk time (0.16 m/s; 95% CI, 0.03-0.3), in fully adjusted models. Initiation ≤3 months versus >3 months was not associated with cardiorespiratory fitness but was associated with a higher but not clinically important Berg Balance Scale score difference (2.9 points; 95% CI, 0.41-5.5). In exercise training versus control studies, initiation ≤3 months was associated with a greater difference in only postintervention 6-minute walk distance (baseline-adjusted 27.3 meters; 95% CI, 6.1-48.5; fully adjusted, 24.9 meters; 95% CI, 0.82-49.1; a similar association was seen for ≤6 months versus >6 months after stroke (fully adjusted, 26.6 meters; 95% CI, 2.6-50.6). Conclusions There may be a clinically meaningful benefit to mobility outcomes when exercise is initiated within 3 months and up to 6 months after stroke.
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Affiliation(s)
- Susan Marzolini
- KITE Research Institute, Toronto Rehabilitation Institute ‐ University Health NetworkTorontoONCanada
- Healthy Living for Pandemic Event Protection (HL–PIVOT) NetworkTorontoONCanada
- Rehabilitation Sciences InstituteUniversity of TorontoONCanada
- Faculty of Kinesiology and Physical EducationUniversity of TorontoONCanada
| | - Che‐Yuan Wu
- Department of Pharmacology and ToxicologyUniversity of TorontoONCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
| | | | - Lisa Y. Xiong
- Department of Pharmacology and ToxicologyUniversity of TorontoONCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
| | - Suban Kangatharan
- KITE Research Institute, Toronto Rehabilitation Institute ‐ University Health NetworkTorontoONCanada
| | - Ardit Peni
- KITE Research Institute, Toronto Rehabilitation Institute ‐ University Health NetworkTorontoONCanada
| | | | - Kylie S.K. Lau
- Department of Human BiologyUniversity of TorontoONCanada
| | | | - Maureen Pakosh
- Library & Information ServicesUniversity Health NetworkToronto Rehabilitation InstituteTorontoONCanada
| | - Stephanie A. Zaban
- Faculty of Kinesiology and Physical EducationUniversity of TorontoONCanada
| | - Michelle M. Nguyen
- Department of Pharmacology and ToxicologyUniversity of TorontoONCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
| | - Mohammad Amin Banihashemi
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
- Institute of Medical ScienceUniversity of TorontoTorontoONCanada
| | - Walter Swardfager
- KITE Research Institute, Toronto Rehabilitation Institute ‐ University Health NetworkTorontoONCanada
- Department of Pharmacology and ToxicologyUniversity of TorontoONCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
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Nascimento LR, Boening A, Galli A, Polese JC, Ada L. Treadmill walking improves walking speed and distance in ambulatory people after stroke and is not inferior to overground walking: a systematic review. J Physiother 2021; 67:95-104. [PMID: 33744188 DOI: 10.1016/j.jphys.2021.02.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 02/16/2021] [Accepted: 02/26/2021] [Indexed: 11/26/2022] Open
Abstract
QUESTIONS Does mechanically assisted walking improve walking speed, distance and participation compared with no/non-walking intervention or overground walking after stroke? Are any benefits maintained beyond the intervention period? DESIGN Systematic review of randomised trials with meta-analysis. PARTICIPANTS Ambulatory adults at any time after stroke. INTERVENTION Mechanically assisted walking (treadmill or gait trainer) without body weight support. OUTCOME MEASURES Walking speed, walking distance and participation. RESULTS Sixteen trials involving 713 participants were included. The mean PEDro score of the trials was 6.3 (range 4 to 8). Treadmill walking increased walking speed by 0.13 m/s (95% CI 0.08 to 0.19) and distance by 46 m (95% CI 24 to 68) compared with no/non-walking intervention; these effects were largely maintained beyond the intervention. Treadmill walking had a similar or better effect on walking speed (MD 0.07 m/s, 95% CI 0.00 to 0.13) and distance (MD 18 m, 95% CI 1 to 36) compared with overground walking. The estimate of the relative effect of treadmill walking compared with overground walking on participation was very imprecise (SMD 0.16, 95% CI -0.15 to 0.48). CONCLUSION This systematic review provides moderate-quality evidence that the effect of treadmill walking is the same as or better than the effect of overground walking for improving walking speed and distance in ambulatory people after stroke. Long-term effects and carryover benefits to participation remain uncertain. REVIEW REGISTRATION PROSPERO (CRD42020162778).
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Affiliation(s)
- Lucas R Nascimento
- Center of Health Sciences, Discipline of Physiotherapy, Universidade Federal do Espírito Santo, Vitória, Brazil; NeuroGroup, Discipline of Physiotherapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
| | - Augusto Boening
- Center of Health Sciences, Discipline of Physiotherapy, Universidade Federal do Espírito Santo, Vitória, Brazil
| | - Abílio Galli
- Center of Health Sciences, Discipline of Physiotherapy, Universidade Federal do Espírito Santo, Vitória, Brazil
| | - Janaine C Polese
- Discipline of Physiotherapy, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil
| | - Louise Ada
- Discipline of Physiotherapy, Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
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Nindorera F, Nduwimana I, Thonnard JL, Kossi O. Effectiveness of walking training on balance, motor functions, activity, participation and quality of life in people with chronic stroke: a systematic review with meta-analysis and meta-regression of recent randomized controlled trials. Disabil Rehabil 2021; 44:3760-3771. [PMID: 33715555 DOI: 10.1080/09638288.2021.1894247] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To review and quantify the effects of walking training for the improvement of various aspects of physical function of people with chronic stroke. METHODS We conducted a systematic search and meta-analysis of randomized controlled trials (RCTs) of chronic stroke rehabilitation interventions published from 2008 to 2020 in English or French. Of the 6476-screened articles collated from four databases, 15 RCTs were included and analyzed. We performed a meta-regression with the total training time as dependent variable in order to have a better understanding of how did the training dosage affect the effect sizes. RESULTS Treadmill walking training was more effective on balance and motor functions (standardized mean difference (SMD)=0.70[0.02, 1.37], p = 0.04) and 0.56[0.15, 0.96], p = 0.007 respectively). Overground walking training improved significantly walking endurance (SMD = 0.38[0.16, 0.59], p < 0.001), walking speed (MD = 0.12[0.05, 0.18], p < 0.001), participation (SMD = 0.35[0.02, 0.68], p = 0.04) and quality of life (SMD = 0.46[0.12, 0.80], p = 0.008). Aquatic training improved balance (SMD = 2.41[1.20, 3.62], p < 0.001). The Meta-regression analysis did not show significant effect of total training time on the effect sizes. CONCLUSION Treadmill and overground walking protocols consisting of ≥30 min sessions conducted at least 3 days per week for about 8 weeks are beneficial for improving motor impairments, activity limitations, participation, and quality of life in people with chronic stroke.Implications for rehabilitationTreadmill walking training is effective for improving balance and motor functions.Overground walking training improved significantly walking endurance, walking speed, participation and quality of life.Treadmill and overground walking protocols consisting of ≥30 min sessions conducted at least 3 days per week for about 8 weeks are beneficial for improving motor impairments, activity limitations, participation, and quality of life in patient with chronic stroke.
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Affiliation(s)
- Félix Nindorera
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium.,National Center for Physical Therapy and Rehabilitation (CNRKR), Bujumbura, Burundi
| | - Ildephonse Nduwimana
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium.,National Center for Physical Therapy and Rehabilitation (CNRKR), Bujumbura, Burundi
| | - Jean Louis Thonnard
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium.,National Center for Physical Therapy and Rehabilitation (CNRKR), Bujumbura, Burundi
| | - Oyéné Kossi
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium.,Unité de NeuroRehabilitation, Service de Neurologie, Hospital Universitaire de Parakou, Parakou, Benin.,ENATSE (Ecole Nationale des Techniciens Supérieurs en Santé Publique et Surveillance Epidémiologique), Université de Parakou, Parakou, Benin
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Abba MA, Olaleye OA, Hamzat TK. Effects of over-ground walking and cognitive rehabilitation on cognition, brain-derived neurotrophic factor, participation and quality of life among stroke survivors: a study protocol. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2020. [DOI: 10.1080/21679169.2020.1808056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Muhammad Aliyu Abba
- Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University Kano, Kano, Nigeria
- Department of Physiotherapy, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Olubukola A. Olaleye
- Department of Physiotherapy, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Talhatu K. Hamzat
- Department of Physiotherapy, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
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Fishbein P, Hutzler Y, Ratmansky M, Treger I, Dunsky A. A Preliminary Study of Dual-Task Training Using Virtual Reality: Influence on Walking and Balance in Chronic Poststroke Survivors. J Stroke Cerebrovasc Dis 2019; 28:104343. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104343] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/24/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022] Open
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Olawale OA, Usman JS, Oke KI, Osundiya OC. Evaluation of Predictive Factors Influencing Community Reintegration in Adult Patients with Stroke. J Neurosci Rural Pract 2019; 9:6-10. [PMID: 29456337 PMCID: PMC5812161 DOI: 10.4103/jnrp.jnrp_386_17] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objectives Patients with stroke are faced with gait, balance, and fall difficulties which could impact on their community reintegration. In Nigeria, community reintegration after stroke has been understudied. The objective of this study was to evaluate the predictors of community reintegration in adult patients with stroke. Materials and Methods Participants were 91 adult patients with stroke. Gait variables, balance self-efficacy, community balance/mobility, and fall self-efficacy were assessed using Rivermead Mobility Index, Activities-specific Balance Confidence Scale, Community Balance and Mobility Scale, and Falls Efficacy Scale-International respectively. Reintegration to Normal Living Index was used to assess satisfaction with community reintegration. Pearson Product-Moment Correlation Coefficient was used to determine the relationship between community reintegration and gait spatiotemporal variables, balance performance, and risk of fall. Multiple regression analysis was used to determine predictors of community reintegration (P ≤ 0.05). Results There was significant positive relationship between community reintegration and cadence (r = 0.250, P = 0.017), functional mobility (r = 0.503, P = 0.001), balance self-efficacy (r = 0.608, P = 0.001), community balance/mobility (r = 0.586, P = 0.001), and duration of stroke (r = 0.220, P = 0.036). Stride time (r = -0.282, P = 0.073) and fall self-efficacy (r = 0.566, P = 0.001) were negatively correlated with community reintegration. Duration of stroke, balance self-efficacy, community balance/mobility, and fall self-efficacy (52.7% of the variance) were the significant predictors of community reintegration. Conclusion Community reintegration is influenced by cadence, functional mobility, balance self-efficacy, community balance/mobility, and duration of stroke. Hence, improving balance and mobility during rehabilitation is important in enhancing community reintegration in patients with stroke.
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Affiliation(s)
| | - Jibrin Sammani Usman
- Department of Physiotherapy, Faculty of Allied Health Sciences, Bayero University, Kano, Nigeria
| | - Kayode Israel Oke
- Department of Physiotherapy, College of Medical Sciences, University of Benin, Benin City, Nigeria
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Dee M, Lennon O, O'Sullivan C. A systematic review of physical rehabilitation interventions for stroke in low and lower-middle income countries. Disabil Rehabil 2018; 42:473-501. [PMID: 30508495 DOI: 10.1080/09638288.2018.1501617] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Purpose: Approximately 70% of strokes occur in low and middle income countries, yet the effectiveness of physical rehabilitation in these contexts remains undetermined. This systematic review identifies and summarises the current evidence supporting physical rehabilitation interventions post-stroke in low and lower-middle income countries.Methods: Five databases were comprehensively searched (April 2017) for randomised controlled trials, clinical controlled trials, and cohort studies testing rehabilitation interventions post-stroke in these countries. The Effective Public Health Practice Project Tool assessed quality of included studies.Results: Sixty-two studies (2115 participants) were included. Interventions addressed upper limb (n = 26), lower limb (n = 22), and other (n = 14) outcomes. Seven studies were rated as strong in quality, 16 moderate and 39 rated as weak. Overall, in addition to usual care, physical rehabilitation interventions improved outcomes for stroke survivors. Best evidence synthesis provides level I (b) evidence supporting constraint induced movement therapy and mirror therapy to improve upper limb functional outcomes. Level I (b) evidence supports multimodal interventions that include lower limb motor imagery to improve gait parameters. Level II (b) evidence supports sit-to-stand training to improve balance outcomes.Conclusions: Exercise-based and brain training interventions improved functional outcomes post-stroke in low and lower-middle income countries. Further high-quality studies including participation outcomes are required.Implications for RehabilitationLow-cost physical rehabilitation interventions requiring minimal resources can improve functional outcomes after stroke in low and lower-middle income countries.Exercise-based interventions can improve upper limb, lower limb, gait, and balance outcomes after stroke.Brain training paradigms such as mirror therapy and motor imagery, when included in therapy packages, can improve upper limb and gait outcomes.The proven efficacy for rehabilitation interventions in improving stroke outcomes in low and lower-middle income countries supports the need to strengthen the rehabilitation workforce in this context.
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Affiliation(s)
- Muireann Dee
- UCD School of Public Health, Physiotherapy and Population Science, University College Dublin, Dublin, Ireland
| | - Olive Lennon
- UCD School of Public Health, Physiotherapy and Population Science, University College Dublin, Dublin, Ireland
| | - Cliona O'Sullivan
- UCD School of Public Health, Physiotherapy and Population Science, University College Dublin, Dublin, Ireland
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Effects of walking trainings on walking function among stroke survivors: a systematic review. Int J Rehabil Res 2018; 41:1-13. [DOI: 10.1097/mrr.0000000000000250] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Treadmill training, with or without body weight support using a harness, is used in rehabilitation and might help to improve walking after stroke. This is an update of the Cochrane review first published in 2003 and updated in 2005 and 2014. OBJECTIVES To determine if treadmill training and body weight support, individually or in combination, improve walking ability, quality of life, activities of daily living, dependency or death, and institutionalisation or death, compared with other physiotherapy gait-training interventions after stroke. The secondary objective was to determine the safety and acceptability of this method of gait training. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched 14 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Reviews of Effects (DARE) (the Cochrane Library 2017, Issue 2), MEDLINE (1966 to 14 February 2017), Embase (1980 to 14 February 2017), CINAHL (1982 to 14 February 2017), AMED (1985 to 14 February 2017) and SPORTDiscus (1949 to 14 February 2017). We also handsearched relevant conference proceedings and ongoing trials and research registers, screened reference lists, and contacted trialists to identify further trials. SELECTION CRITERIA Randomised or quasi-randomised controlled and cross-over trials of treadmill training and body weight support, individually or in combination, for the treatment of walking after stroke. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted data, and assessed risk of bias and methodological quality. The primary outcomes investigated were walking speed, endurance, and dependency. MAIN RESULTS We included 56 trials with 3105 participants in this updated review. The average age of the participants was 60 years, and the studies were carried out in both inpatient and outpatient settings. All participants had at least some walking difficulties and many could not walk without assistance. Overall, the use of treadmill training did not increase the chances of walking independently compared with other physiotherapy interventions (risk difference (RD) -0.00, 95% confidence interval (CI) -0.02 to 0.02; 18 trials, 1210 participants; P = 0.94; I² = 0%; low-quality evidence). Overall, the use of treadmill training in walking rehabilitation for people after stroke increased the walking velocity and walking endurance significantly. The pooled mean difference (MD) (random-effects model) for walking velocity was 0.06 m/s (95% CI 0.03 to 0.09; 47 trials, 2323 participants; P < 0.0001; I² = 44%; moderate-quality evidence) and the pooled MD for walking endurance was 14.19 metres (95% CI 2.92 to 25.46; 28 trials, 1680 participants; P = 0.01; I² = 27%; moderate-quality evidence). Overall, the use of treadmill training with body weight support in walking rehabilitation for people after stroke did not increase the walking velocity and walking endurance at the end of scheduled follow-up. The pooled MD (random-effects model) for walking velocity was 0.03 m/s (95% CI -0.05 to 0.10; 12 trials, 954 participants; P = 0.50; I² = 55%; low-quality evidence) and the pooled MD for walking endurance was 21.64 metres (95% CI -4.70 to 47.98; 10 trials, 882 participants; P = 0.11; I² = 47%; low-quality evidence). In 38 studies with a total of 1571 participants who were independent in walking at study onset, the use of treadmill training increased the walking velocity significantly. The pooled MD (random-effects model) for walking velocity was 0.08 m/s (95% CI 0.05 to 0.12; P < 0.00001; I2 = 49%). There were insufficient data to comment on any effects on quality of life or activities of daily living. Adverse events and dropouts did not occur more frequently in people receiving treadmill training and these were not judged to be clinically serious events. AUTHORS' CONCLUSIONS Overall, people after stroke who receive treadmill training, with or without body weight support, are not more likely to improve their ability to walk independently compared with people after stroke not receiving treadmill training, but walking speed and walking endurance may improve slightly in the short term. Specifically, people with stroke who are able to walk (but not people who are dependent in walking at start of treatment) appear to benefit most from this type of intervention with regard to walking speed and walking endurance. This review did not find, however, that improvements in walking speed and endurance may have persisting beneficial effects. Further research should specifically investigate the effects of different frequencies, durations, or intensities (in terms of speed increments and inclination) of treadmill training, as well as the use of handrails, in ambulatory participants, but not in dependent walkers.
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Affiliation(s)
- Jan Mehrholz
- Technical University DresdenDepartment of Public Health, Dresden Medical SchoolFetscherstr. 74DresdenGermany01307
| | - Simone Thomas
- Klinik Bavaria KreischaWissenschaftliches InstitutKreischaGermany01731
| | - Bernhard Elsner
- Dresden Medical School, Technical University DresdenDepartment of Public HealthFetscherstr. 74DresdenSachsenGermany01307
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French B, Thomas LH, Coupe J, McMahon NE, Connell L, Harrison J, Sutton CJ, Tishkovskaya S, Watkins CL. Repetitive task training for improving functional ability after stroke. Cochrane Database Syst Rev 2016; 11:CD006073. [PMID: 27841442 PMCID: PMC6464929 DOI: 10.1002/14651858.cd006073.pub3] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation. OBJECTIVES Primary objective: To determine if RTT improves upper limb function/reach and lower limb function/balance in adults after stroke. Secondary objectives: 1) To determine the effect of RTT on secondary outcome measures including activities of daily living, global motor function, quality of life/health status and adverse events. 2) To determine the factors that could influence primary and secondary outcome measures, including the effect of 'dose' of task practice; type of task (whole therapy, mixed or single task); timing of the intervention and type of intervention. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (4 March 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 5: 1 October 2006 to 24 June 2016); MEDLINE (1 October 2006 to 8 March 2016); Embase (1 October 2006 to 8 March 2016); CINAHL (2006 to 23 June 2016); AMED (2006 to 21 June 2016) and SPORTSDiscus (2006 to 21 June 2016). SELECTION CRITERIA Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal. DATA COLLECTION AND ANALYSIS Two review authors independently screened abstracts, extracted data and appraised trials. We determined the quality of evidence within each study and outcome group using the Cochrane 'Risk of bias' tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. We did not assess follow-up outcome data using GRADE. We contacted trial authors for additional information. MAIN RESULTS We included 33 trials with 36 intervention-control pairs and 1853 participants. The risk of bias present in many studies was unclear due to poor reporting; the evidence has therefore been rated 'moderate' or 'low' when using the GRADE system. There is low-quality evidence that RTT improves arm function (standardised mean difference (SMD) 0.25, 95% confidence interval (CI) 0.01 to 0.49; 11 studies, number of participants analysed = 749), hand function (SMD 0.25, 95% CI 0.00 to 0.51; eight studies, number of participants analysed = 619), and lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48; five trials, number of participants analysed = 419). There is moderate-quality evidence that RTT improves walking distance (mean difference (MD) 34.80, 95% CI 18.19 to 51.41; nine studies, number of participants analysed = 610) and functional ambulation (SMD 0.35, 95% CI 0.04 to 0.66; eight studies, number of participants analysed = 525). We found significant differences between groups for both upper-limb (SMD 0.92, 95% CI 0.58 to 1.26; three studies, number of participants analysed = 153) and lower-limb (SMD 0.34, 95% CI 0.16 to 0.52; eight studies, number of participants analysed = 471) outcomes up to six months post treatment but not after six months. Effects were not modified by intervention type, dosage of task practice or time since stroke for upper or lower limb. There was insufficient evidence to be certain about the risk of adverse events. AUTHORS' CONCLUSIONS There is low- to moderate-quality evidence that RTT improves upper and lower limb function; improvements were sustained up to six months post treatment. Further research should focus on the type and amount of training, including ways of measuring the number of repetitions actually performed by participants. The definition of RTT will need revisiting prior to further updates of this review in order to ensure it remains clinically meaningful and distinguishable from other interventions.
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Affiliation(s)
- Beverley French
- University of Central LancashireDepartment of Nursing and Caring SciencesRoom 434Brook BuildingPrestonLancashireUKPR1 2HE
| | - Lois H Thomas
- University of Central LancashireCollege of Health and WellbeingRoom 326Brook BuildingPrestonLancashireUKPR1 2HE
| | - Jacqueline Coupe
- University of Central LancashireCollege of Health and WellbeingRoom 326Brook BuildingPrestonLancashireUKPR1 2HE
| | - Naoimh E McMahon
- University of Central LancashireCollege of Health and WellbeingRoom 326Brook BuildingPrestonLancashireUKPR1 2HE
| | - Louise Connell
- University of Central LancashireCollege of Health and WellbeingRoom 326Brook BuildingPrestonLancashireUKPR1 2HE
| | - Joanna Harrison
- University of Central LancashireDepartment of NursingPrestonLancashireUKPR1 2HE
| | - Christopher J Sutton
- University of Central LancashireCollege of Health and WellbeingRoom 326Brook BuildingPrestonLancashireUKPR1 2HE
| | | | - Caroline L Watkins
- University of Central LancashireCollege of Health and WellbeingRoom 326Brook BuildingPrestonLancashireUKPR1 2HE
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Effect of Aerobic Exercise Interventions on Mobility among Stroke Patients: A Systematic Review. Am J Phys Med Rehabil 2016; 95:214-24. [PMID: 26544857 DOI: 10.1097/phm.0000000000000416] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this systematic review was to examine studies that examined the effectiveness of aerobic exercise interventions on mobility in long-term stroke survivors. DESIGN The authors searched electronic databases for randomized control trials between January 1995 and December 2014 investigating aerobic exercise interventions and mobility in stroke survivors after the subacute phase (>6 mos). Mobility was measured using objective functional fitness tests: 6-minute walk, 10-meter walk, and up-n-go. RESULTS Nine randomized control trials that compared aerobic exercise with a control group among stroke survivors (mean age, 56.95-68 yrs) were identified. Aerobic interventions lasted between 2 and 6 mos and primarily involved walking. Using the Comprehensive Meta-analysis software, it was found that two of the three mobility outcomes showed small to moderate effect sizes favoring the aerobic exercise group: 6-minute walk (g = 0.366, P < 0.001) and 10-meter walk (g = 0.411, P = 0.002), while the up-n-go test was not significant (g = -0.150, P = 0.330). CONCLUSION These findings demonstrate that stroke survivors may continue to benefit from aerobic exercise after the subacute phase. Future research needs to examine the precise dose and recommendation for aerobic exercise, test other exercise modalities, and use larger samples to thoroughly determine long-term exercise effects on mobility in this population.
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Saunders DH, Sanderson M, Hayes S, Kilrane M, Greig CA, Brazzelli M, Mead GE. Physical fitness training for stroke patients. Cochrane Database Syst Rev 2016; 3:CD003316. [PMID: 27010219 PMCID: PMC6464717 DOI: 10.1002/14651858.cd003316.pub6] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability. OBJECTIVES To determine whether fitness training after stroke reduces death, dependence, and disability and to assess the effects of training with regard to adverse events, risk factors, physical fitness, mobility, physical function, quality of life, mood, and cognitive function. Interventions to improve cognitive function have attracted increased attention after being identified as the highest rated research priority for life after stroke. Therefore we have added this class of outcomes to this updated review. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 1: searched February 2015), MEDLINE (1966 to February 2015), EMBASE (1980 to February 2015), CINAHL (1982 to February 2015), SPORTDiscus (1949 to February 2015), and five additional databases (February 2015). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field. SELECTION CRITERIA Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses. Diverse outcome measures limited the intended analyses. MAIN RESULTS We included 58 trials, involving 2797 participants, which comprised cardiorespiratory interventions (28 trials, 1408 participants), resistance interventions (13 trials, 432 participants), and mixed training interventions (17 trials, 957 participants). Thirteen deaths occurred before the end of the intervention and a further nine before the end of follow-up. No dependence data were reported. Diverse outcome measures restricted pooling of data. Global indices of disability show moderate improvement after cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) 0.19 to 0.84; P value = 0.002) and by a small amount after mixed training (SMD 0.26, 95% CI 0.04 to 0.49; P value = 0.02); benefits at follow-up (i.e. after training had stopped) were unclear. There were too few data to assess the effects of resistance training.Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 6.71 metres per minute, 95% CI 2.73 to 10.69), preferred gait speed (MD 4.28 metres per minute, 95% CI 1.71 to 6.84), and walking capacity (MD 30.29 metres in six minutes, 95% CI 16.19 to 44.39) at the end of the intervention. Mixed training, involving walking, increased preferred walking speed (MD 4.54 metres per minute, 95% CI 0.95 to 8.14), and walking capacity (MD 41.60 metres per six minutes, 95% CI 25.25 to 57.95). Balance scores improved slightly after mixed training (SMD 0.27, 95% CI 0.07 to 0.47). Some mobility benefits also persisted at the end of follow-up. The variability, quality of the included trials, and lack of data prevents conclusions about other outcomes and limits generalisability of the observed results. AUTHORS' CONCLUSIONS Cardiorespiratory training and, to a lesser extent, mixed training reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve the speed and tolerance of walking; some improvement in balance could also occur. There is insufficient evidence to support the use of resistance training. The effects of training on death and dependence after stroke are still unclear but these outcomes are rarely observed in physical fitness training trials. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription and identify long-term benefits.
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Affiliation(s)
- David H Saunders
- Institute for Sport, Physical Education and Health Sciences (SPEHS), University of EdinburghMoray House School of EducationSt Leonards LandHolyrood RoadEdinburghUKEH8 2AZ
| | - Mark Sanderson
- University of the West of ScotlandInstitute of Clinical Exercise and Health ScienceRoom A071A, Almada BuildingHamiltonUKML3 0JB
| | - Sara Hayes
- University of LimerickDepartment of Clinical TherapiesLimerickIreland
| | - Maeve Kilrane
- Royal Infirmary of EdinburghDepartment of Stroke MedicineWard 201 ‐ Stroke UnitLittle FranceEdinburghUKEH16 4SA
| | - Carolyn A Greig
- University of BirminghamSchool of Sport, Exercise and Rehabilitation Sciences, MRC‐ARUK Centre for Musculoskeletal Ageing ResearchEdgbastonBirminghamUKB15 2TT
| | - Miriam Brazzelli
- University of AberdeenHealth Services Research UnitHealth Sciences BuildingForesterhillAberdeenUKAB25 2ZD
| | - Gillian E Mead
- University of EdinburghCentre for Clinical Brain SciencesRoom S1642, Royal InfirmaryLittle France CrescentEdinburghUKEH16 4SA
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Ajiboye O, Anigbogu C, Ajuluchukwu J, Jaja S. Exercise training improves functional walking capacity and activity level of Nigerians with chronic biventricular heart failure. Hong Kong Physiother J 2015. [DOI: 10.1016/j.hkpj.2014.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Protocol variations and six-minute walk test performance in stroke survivors: a systematic review with meta-analysis. Stroke Res Treat 2015; 2015:484813. [PMID: 25685596 PMCID: PMC4320847 DOI: 10.1155/2015/484813] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/18/2014] [Accepted: 12/18/2014] [Indexed: 11/17/2022] Open
Abstract
Objective. To investigate the use of the six-minute walk test (6MWT) for stroke survivors, including adherence to 6MWT protocol guidelines and distances achieved. Methods. A systematic search was conducted from inception to March 2014. Included studies reported a baseline (intervention studies) or first instance (observational studies) measure for the 6MWT performed by stroke survivors regardless of time after stroke. Results. Of 127 studies (participants n = 6,012) that met the inclusion criteria, 64 were also suitable for meta-analysis. Only 25 studies made reference to the American Thoracic Society (ATS) standards for the 6MWT, and 28 reported using the protocol standard 30 m walkway. Thirty-nine studies modified the protocol walkway, while 60 studies did not specify the walkway used. On average, stroke survivors walked 284 ± 107 m during the 6MWT, which is substantially less than healthy age-matched individuals. The meta-analysis identified that changes to the ATS protocol walkway are associated with reductions in walking distances achieved. Conclusion. The 6MWT is now widely used in stroke studies. The distances achieved by stroke patients indicate substantially compromised walking ability. Variations to the standard 30 m walkway for the 6MWT are common and caution should be used when comparing the values achieved from studies using different walkway lengths.
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Ajiboye OA, Anigbogu CN, Ajuluchukwu JN, Jaja SI. Prediction equations for 6-minute walk distance in apparently healthy Nigerians. Hong Kong Physiother J 2014. [DOI: 10.1016/j.hkpj.2014.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Veerbeek JM, van Wegen E, van Peppen R, van der Wees PJ, Hendriks E, Rietberg M, Kwakkel G. What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PLoS One 2014; 9:e87987. [PMID: 24505342 PMCID: PMC3913786 DOI: 10.1371/journal.pone.0087987] [Citation(s) in RCA: 675] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 12/30/2013] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT. METHODS AND FINDINGS Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N = 25373; median PEDro score 6 [IQR 5-7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03-0.70; I(2) = 0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84-4.11; I(2) = 77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02-0.39; I(2) = 6%) for motor function of the paretic arm to 0.61 (95%CI 0.41-0.82; I(2) = 41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing. CONCLUSIONS There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.
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Affiliation(s)
- Janne Marieke Veerbeek
- Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Erwin van Wegen
- Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Roland van Peppen
- Department of Physiotherapy, University of Applied Sciences Utrecht, Utrecht, The Netherlands
| | - Philip Jan van der Wees
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Erik Hendriks
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Marc Rietberg
- Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Gert Kwakkel
- Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
- Department of Neurorehabilitation, Reade Center for Rehabilitation and Rheumatology, Amsterdam, The Netherlands
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Abstract
BACKGROUND Treadmill training, with or without body weight support using a harness, is used in rehabilitation and might help to improve walking after stroke. This is an update of a Cochrane review first published in 2005. OBJECTIVES To determine if treadmill training and body weight support, individually or in combination, improve walking ability, quality of life, activities of daily living, dependency or death, and institutionalisation or death, compared with other physiotherapy gait training interventions after stroke. The secondary objective was to determine the safety and acceptability of this method of gait training. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched June 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Reviews of Effects (DARE) (The Cochrane Library 2013, Issue 7), MEDLINE (1966 to July 2013), EMBASE (1980 to July 2013), CINAHL (1982 to June 2013), AMED (1985 to July 2013) and SPORTDiscus (1949 to June 2013). We also handsearched relevant conference proceedings and ongoing trials and research registers, screened reference lists and contacted trialists to identify further trials. SELECTION CRITERIA Randomised or quasi-randomised controlled and cross-over trials of treadmill training and body weight support, individually or in combination, for the treatment of walking after stroke. DATA COLLECTION AND ANALYSIS Two authors independently selected trials, extracted data and assessed methodological quality. The primary outcomes investigated were walking speed, endurance and dependency. MAIN RESULTS We included 44 trials with 2658 participants in this updated review. Overall, the use of treadmill training with body weight support did not increase the chances of walking independently compared with other physiotherapy interventions (risk difference (RD) -0.00, 95% confidence interval (CI) -0.02 to 0.02; P = 0.94; I² = 0%). Overall, the use of treadmill training with body weight support in walking rehabilitation for patients after stroke increased the walking velocity and walking endurance significantly. The pooled mean difference (MD) (random-effects model) for walking velocity was 0.07 m/s (95% CI 0.01 to 0.12; P = 0.02; I² = 57%) and the pooled MD for walking endurance was 26.35 metres (95% CI 2.51 to 50.19; P = 0.03; I² = 60%). Overall, the use of treadmill training with body weight support in walking rehabilitation for patients after stroke did not increase the walking velocity and walking endurance at the end of scheduled follow-up significantly. The pooled MD (random-effects model) for walking velocity was 0.04 m/s (95% CI -0.06 to 0.14; P = 0.40; I² = 40%) and the pooled MD for walking endurance was 32.36 metres (95% CI -3.10 to 67.81; P = 0.07; I² = 63%). However, for ambulatory patients improvements in walking endurance lasted until the end of scheduled follow-up (MD 58.88 metres, 95% CI 29.10 to 88.66; P = 0.0001; I² = 0%). Adverse events and drop outs did not occur more frequently in people receiving treadmill training and these were not judged to be clinically serious events. AUTHORS' CONCLUSIONS Overall, people after stroke who receive treadmill training with or without body weight support are not more likely to improve their ability to walk independently compared with people after stroke not receiving treadmill training, but walking speed and walking endurance may improve. Specifically, stroke patients who are able to walk (but not people who are not able to walk) appear to benefit most from this type of intervention. This review found that improvements in walking endurance in people able to walk may have persisting beneficial effects. Further research should specifically investigate the effects of different frequencies, durations or intensities (in terms of speed increments and inclination) of treadmill training, as well as the use of handrails, in ambulatory patients, but not in dependent walkers.
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Affiliation(s)
- Jan Mehrholz
- Private Europäische Medizinische Akademie der Klinik Bavaria in Kreischa GmbHWissenschaftliches InstitutAn der Wolfsschlucht 1‐2KreischaGermany01731
| | - Marcus Pohl
- Klinik Bavaria KreischaAbteilung Neurologie und Fachübergreifende RehabilitationAn der Wolfsschlucht 1‐2KreischaGermany01731
| | - Bernhard Elsner
- Technical University DresdenDepartment of Public Health, Dresden Medical SchoolFetscherstr. 74DresdenGermany01307
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20
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Abstract
BACKGROUND Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability. OBJECTIVES To determine whether fitness training after stroke reduces death, dependence, and disability. The secondary aims were to determine the effects of training on physical fitness, mobility, physical function, quality of life, mood, and incidence of adverse events. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched January 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12: searched January 2013), MEDLINE (1966 to January 2013), EMBASE (1980 to January 2013), CINAHL (1982 to January 2013), SPORTDiscus (1949 to January 2013), and five additional databases (January 2013). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field. SELECTION CRITERIA Randomised trials comparing either cardiorespiratory training or resistance training, or both, with no intervention, a non-exercise intervention, or usual care in stroke survivors. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed quality, and extracted data. We analysed data using random-effects meta-analyses. Diverse outcome measures limited the intended analyses. MAIN RESULTS We included 45 trials, involving 2188 participants, which comprised cardiorespiratory (22 trials, 995 participants), resistance (eight trials, 275 participants), and mixed training interventions (15 trials, 918 participants). Nine deaths occurred before the end of the intervention and a further seven at the end of follow-up. No dependence data were reported. Diverse outcome measures made data pooling difficult. Global indices of disability show a tendency to improve after cardiorespiratory training (standardised mean difference (SMD) 0.37, 95% confidence interval (CI) 0.10 to 0.64; P = 0.007); benefits at follow-up and after mixed training were unclear. There were insufficient data to assess the effects of resistance training.Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 7.37 metres per minute, 95% CI 3.70 to 11.03), preferred gait speed (MD 4.63 metres per minute, 95% CI 1.84 to 7.43), walking capacity (MD 26.99 metres per six minutes, 95% CI 9.13 to 44.84), and Berg Balance scores (MD 3.14, 95% CI 0.56 to 5.73) at the end of the intervention. Mixed training, involving walking, increased preferred walking speed (MD 4.54 metres per minute, 95% CI 0.95 to 8.14), walking capacity (MD 41.60 metres per six minutes, 95% CI 25.25 to 57.95), and also pooled balance scores but the evidence is weaker (SMD 0.26 95% CI 0.04 to, 0.49). Some mobility benefits also persisted at the end of follow-up. The variability and trial quality hampered the assessment of the reliability and generalisability of the observed results. AUTHORS' CONCLUSIONS The effects of training on death and dependence after stroke are unclear. Cardiorespiratory training reduces disability after stroke and this may be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programs to improve the speed and tolerance of walking; improvement in balance may also occur. There is insufficient evidence to support the use of resistance training. Further well-designed trials are needed to determine the optimal content of the exercise prescription and identify long-term benefits.
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Affiliation(s)
- David H Saunders
- Moray House School of Education, Institute for Sport, Physical Education and Health Sciences (SPEHS), University of Edinburgh, St Leonards Land, Holyrood Road, Edinburgh, Midlothian, UK, EH8 2AZ
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Polese JC, Ada L, Dean CM, Nascimento LR, Teixeira-Salmela LF. Treadmill training is effective for ambulatory adults with stroke: a systematic review. J Physiother 2013; 59:73-80. [PMID: 23663792 DOI: 10.1016/s1836-9553(13)70159-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
QUESTION Does mechanically assisted walking increase walking speed or distance in ambulatory people with stroke compared with no intervention/non-walking intervention, or with overground walking? DESIGN Systematic review with meta-analysis of randomised trials. PARTICIPANTS Ambulatory adults with stroke. INTERVENTION Mechanically assisted walking (treadmill or gait trainer) without body weight support. OUTCOME MEASURES Walking speed measured in m/s during the 10-m Walk Test and walking distance measured in m during the 6-min Walk Test. RESULTS Nine studies of treadmill training comprising 977 participants were included. Treadmill training resulted in faster walking than no intervention/non-walking intervention immediately after the intervention period (MD 0.14m/s, 95% CI 0.09 to 0.19) and this was maintained beyond the intervention period (MD -0.12m/s, 95% CI 0.08 to 0.17). It also resulted in greater walking distance immediately after the intervention period (MD 40m, 95% CI 27 to 53) and this was also maintained beyond the intervention period (MD 40m, 95% CI 24 to 55). There was no immediate, statistically significant difference between treadmill training and overground training in terms of walking speed (MD 0.05m/s, 95% CI 0.12 to 0.21) or distance (MD -6m, 95% CI -45 to 33). CONCLUSION This systematic review provides evidence that, for people with stroke who can walk, treadmill training without body weight support results in faster walking speed and greater distance than no intervention/ non-walking intervention and the benefit is maintained beyond the training period.
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Affiliation(s)
- Janaine C Polese
- Discipline of Physiotherapy, The University of Sydney, Australia
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Yoon J, Park HS, Damiano DL. A novel walking speed estimation scheme and its application to treadmill control for gait rehabilitation. J Neuroeng Rehabil 2012; 9:62. [PMID: 22929169 PMCID: PMC3546912 DOI: 10.1186/1743-0003-9-62] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 08/15/2012] [Indexed: 11/10/2022] Open
Abstract
Background Virtual reality (VR) technology along with treadmill training (TT) can effectively provide goal-oriented practice and promote improved motor learning in patients with neurological disorders. Moreover, the VR + TT scheme may enhance cognitive engagement for more effective gait rehabilitation and greater transfer to over ground walking. For this purpose, we developed an individualized treadmill controller with a novel speed estimation scheme using swing foot velocity, which can enable user-driven treadmill walking (UDW) to more closely simulate over ground walking (OGW) during treadmill training. OGW involves a cyclic acceleration-deceleration profile of pelvic velocity that contrasts with typical treadmill-driven walking (TDW), which constrains a person to walk at a preset constant speed. In this study, we investigated the effects of the proposed speed adaptation controller by analyzing the gait kinematics of UDW and TDW, which were compared to those of OGW at three pre-determined velocities. Methods Ten healthy subjects were asked to walk in each mode (TDW, UDW, and OGW) at three pre-determined speeds (0.5 m/s, 1.0 m/s, and 1.5 m/s) with real time feedback provided through visual displays. Temporal-spatial gait data and 3D pelvic kinematics were analyzed and comparisons were made between UDW on a treadmill, TDW, and OGW. Results The observed step length, cadence, and walk ratio defined as the ratio of stride length to cadence were not significantly different between UDW and TDW. Additionally, the average magnitude of pelvic acceleration peak values along the anterior-posterior direction for each step and the associated standard deviations (variability) were not significantly different between the two modalities. The differences between OGW and UDW and TDW were mainly in swing time and cadence, as have been reported previously. Also, step lengths between OGW and TDW were different for 0.5 m/s and 1.5 m/s gait velocities, and walk ratio between OGS and UDW was different for 1.0 m/s gait velocities. Conclusions Our treadmill control scheme implements similar gait biomechanics of TDW, which has been used for repetitive gait training in a small and constrained space as well as controlled and safe environments. These results reveal that users can walk as stably during UDW as TDW and employ similar strategies to maintain walking speed in both UDW and TDW. Furthermore, since UDW can allow a user to actively participate in the virtual reality (VR) applications with variable walking velocity, it can induce more cognitive activities during the training with VR, which may enhance motor learning effects.
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Affiliation(s)
- Jungwon Yoon
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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