Efficacy of Functional Strength Training on Restoration of Lower-Limb Motor Function Early After Stroke: Phase I Randomized Controlled Trial

Clinimetric evaluation of five clinically feasible measures of the leg extensor muscle strength in neurological rehabilitation settings

A gold-standard clinical measure of leg muscle strength has not been established. Therefore, the aim of this study was to evaluate clinimetric properties of five clinically feasible measures of lower-limb extensor muscle strength in neurological rehabilitation settings. This was a cross-sectional observational study of 36 participants with leg weakness as a result of a neurological condition/injury. Participants were recruited across a range of walking abilities, from non- to independently ambulant. Each was assessed using each of the following five measures: manual muscle test (MMT), hand-held dynamometry (HHD), seated single leg press one repetition maximum (1RM), functional sit-to-stand (STS) test and seated single leg press measured with a load cell. Each clinical measure was evaluated for its discriminative ability, floor/ceiling effects, test-retest reliability and clinical utility. The load cell and HHD were the most discriminative of the tests and were also resistant to floor/ceiling effects; however, the load cell was superior to the HHD when compared for its clinical utility. The MMT/STS tests received perfect scores for clinical utility, although similar to the 1RM test, they were susceptible to floor and ceiling effects. The load cell leg press test was the only measure of lower limb strength to satisfy all four clinimetric properties. Implications for clinical practice include, firstly, that strength tests available to clinicians vary in their clinimetric properties. Secondly, the functional status of the person will determine selection of the best clinical strength test. And lastly, load cell device technology should be considered for clinical strength assessments.

Impact of Functional Training on Functional Movement and Athletic Performance in College Dragon Boat Athletes

Functional training has become a popular training method in different sports, yet limited studies have focused on paddle sports. The purpose of this study was to evaluate the effects of functional training on functional movement and athletic performance in college dragon boat athletes. A total of 42 male athletes were divided into 2 groups: a functional training (FT) group (n = 21, 21 ± 1.47 years) and a regular training (RT) group (n = 21, 22 ± 1.50 years). The FT group participated in an 8-week (16-session) functional-training program, while the RT group trained with strength-training sessions. Functional movement screen (FMS), Y-balance test (YBT) and athletic performance evaluations were conducted before and after the intervention. Repeated measure ANOVA and t-test evaluations were employed to examine differences for both groups. The FT group was significantly improved in FMS scores (F = 0.191, p < 0.001) and YBT scores (F = 2.59, p = 0.027), and it also showed significantly improved muscular fitness (pull-ups: F = 0.127, p < 0.001; push-ups: F = 1.43, p < 0.001) and rowing speed (F = 4.37, p = 0.004). It is recommended to include functional training as a part of training and routine exercise, as it appears to be an effective way of improving FMS and athletic performance in paddle sports.

Synergistic effect of functional strength training and cognitive intervention on gross motor function in children with cerebral palsy

BACKGROUND

Cerebral palsy (CP) is a posture and movement disorder, however; it often includes disturbance of different aspects of cognitive function. This study aimed to investigate if combined functional strength training (FST) and cognitive intervention are more effective than either of them alone on gross motor function in children with spastic diplegic CP.

METHODS

Sixty-four children with spastic diplegic CP, with ages ranging from 8 to 12 years, were assigned randomly into four treatment groups; Group I; FST, group II; cognitive training, group III; combined FST and cognitive training, group IV; conventional physical therapy. The Gross Motor Function Measure (GMFM-88) was used to assess gross motor function at baseline, post-treatment, and 6 months follow-up.

RESULTS

Group III achieved a significant improvement in GMFM-88 when compared to other groups post-treatment and at follow-up.

CONCLUSION

This study suggests that combined lower limb FST and cognitive intervention had the potential to produce significantly more favorable effects than the single use of either of them on gross motor function in children with spastic diplegia.

The effects of rehabilitation therapy duration on functional recovery of patients with subacute stroke stratified by individual's age: a retrospective multicenter study

BACKGROUND

The duration of rehabilitation therapy is one of the key elements for promoting post-stroke functional recovery. However, whether an individual's age affects the effectiveness of the duration of rehabilitation therapy on post-stroke functional recovery remains unclear.

AIM

This study aimed to investigate whether age has an influence on the relationship between the duration of rehabilitation therapy and post-stroke functional recovery.

DESIGN

This is a retrospective observational study.

SETTING

Six convalescent inpatient rehabilitation hospitals in Japan.

POPULATION

The population of the study was represented by a total of 1186 participants with subacute stroke.

METHODS

Participants were stratified into four groups according to their age (≤59, 60-69, 70-79, and ≥80 years). The data of minutes involved in performing rehabilitation therapy for participants during hospitalization per day (extracted from the medical records of each hospital). The outcome measurement was the absolute change in the functional independence measure (FIM) score during hospitalization.

RESULTS

The mean FIM gains in the ≤59 years, 60-69 years, 70-79 years, and the ≥80 years groups were 38.7 (18.8), 32.8 (18.0), 29.7 (16.6), and 25.4 (17.2), respectively. The results of the multivariate regression analyses showed that there was a significant association between the duration of daily rehabilitation therapy and the FIM gain in the 70-79 years and the ≥80 years groups (-70-79 years group: B=1.289, β=0.290, 95% confidence intervals (CIs): 0.718-1.859, P<0.001; the ≥80 years group: B=2.375, β=0.371, 95% CIs: 1.644-3.107, P<0.001), but not in the other groups.

CONCLUSIONS

For patients with subacute stroke in rehabilitation hospitals, a higher duration of daily rehabilitation therapy was associated with better functional recovery in the 70-79 years group and ≥80 years groups. Understanding the responsiveness of patients with stroke to rehabilitation therapy by age group helps to better allocate medical resources and develop more effective approaches.

CLINICAL REHABILITATION IMPACT

An increased duration of daily rehabilitation therapy may be helpful in older adults with stroke selected for intensive rehabilitation for improvement of basic daily functioning.

Functional resistance training methods for targeting patient-specific gait deficits: A review of devices and their effects on muscle activation, neural control, and gait mechanics

BACKGROUND

Injuries to the neuromusculoskeletal system often result in weakness and gait impairments. Functional resistance training during walking-where patients walk while a device increases loading on the leg-is an emerging approach to combat these symptoms. However, there are many methods that can be used to resist the patient, which may alter the biomechanics of the training. Thus, all methods may not address patient-specific deficits.

METHODS

We performed a comprehensive electronic database search to identify articles that acutely (i.e., after a single training session) examined how functional resistance training during walking alters muscle activation, gait biomechanics, and neural plasticity. Only articles that examined these effects during training or following the removal of resistance (i.e., aftereffects) were included.

FINDINGS

We found 41 studies that matched these criteria. Most studies (24) used passive devices (e.g., weighted cuffs or resistance bands) while the remainder used robotic devices. Devices varied on if they were wearable (14) or externally tethered, and the type of resistance they applied (i.e., inertial [14], elastic [8], viscous [7], or customized [12]). Notably, these methods provided device-specific changes in muscle activation, biomechanics, and spatiotemporal and kinematic aftereffects. Some evidence suggests this training results in task-specific increases in neural excitability.

INTERPRETATION

These findings suggest that careful selection of resistive strategies could help target patient-specific strength deficits and gait impairments. Also, many approaches are low-cost and feasible for clinical or in-home use. The results provide new insights for clinicians on selecting an appropriate functional resistance training strategy to target patient-specific needs.

The effect of time spent in rehabilitation on activity limitation and impairment after stroke

BACKGROUND

Stroke affects millions of people every year and is a leading cause of disability, resulting in significant financial cost and reduction in quality of life. Rehabilitation after stroke aims to reduce disability by facilitating recovery of impairment, activity, or participation. One aspect of stroke rehabilitation that may affect outcomes is the amount of time spent in rehabilitation, including minutes provided, frequency (i.e. days per week of rehabilitation), and duration (i.e. time period over which rehabilitation is provided). Effect of time spent in rehabilitation after stroke has been explored extensively in the literature, but findings are inconsistent. Previous systematic reviews with meta-analyses have included studies that differ not only in the amount provided, but also type of rehabilitation.

OBJECTIVES

To assess the effect of 1. more time spent in the same type of rehabilitation on activity measures in people with stroke; 2. difference in total rehabilitation time (in minutes) on recovery of activity in people with stroke; and 3. rehabilitation schedule on activity in terms of: a. average time (minutes) per week undergoing rehabilitation, b. frequency (number of sessions per week) of rehabilitation, and c. total duration of rehabilitation.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, eight other databases, and five trials registers to June 2021. We searched reference lists of identified studies, contacted key authors, and undertook reference searching using Web of Science Cited Reference Search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adults with stroke that compared different amounts of time spent, greater than zero, in rehabilitation (any non-pharmacological, non-surgical intervention aimed to improve activity after stroke). Studies varied only in the amount of time in rehabilitation between experimental and control conditions. Primary outcome was activities of daily living (ADLs); secondary outcomes were activity measures of upper and lower limbs, motor impairment measures of upper and lower limbs, and serious adverse events (SAE)/death.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies, extracted data, assessed methodological quality using the Cochrane RoB 2 tool, and assessed certainty of the evidence using GRADE. For continuous outcomes using different scales, we calculated pooled standardised mean difference (SMDs) and 95% confidence intervals (CIs). We expressed dichotomous outcomes as risk ratios (RR) with 95% CIs.

MAIN RESULTS

The quantitative synthesis of this review comprised 21 parallel RCTs, involving analysed data from 1412 participants.  Time in rehabilitation varied between studies. Minutes provided per week were 90 to 1288. Days per week of rehabilitation were three to seven. Duration of rehabilitation was two weeks to six months. Thirteen studies provided upper limb rehabilitation, five general rehabilitation, two mobilisation training, and one lower limb training. Sixteen studies examined participants in the first six months following stroke; the remaining five included participants more than six months poststroke. Comparison of stroke severity or level of impairment was limited due to variations in measurement. The risk of bias assessment suggests there were issues with the methodological quality of the included studies. There were 76 outcome-level risk of bias assessments: 15 low risk, 37 some concerns, and 24 high risk. When comparing groups that spent more time versus less time in rehabilitation immediately after intervention, we found no difference in rehabilitation for ADL outcomes (SMD 0.13, 95% CI -0.02 to 0.28; P = 0.09; I2 = 7%; 14 studies, 864 participants; very low-certainty evidence), activity measures of the upper limb (SMD 0.09, 95% CI -0.11 to 0.29; P = 0.36; I2 = 0%; 12 studies, 426 participants; very low-certainty evidence), and activity measures of the lower limb (SMD 0.25, 95% CI -0.03 to 0.53; P = 0.08; I2 = 48%; 5 studies, 425 participants; very low-certainty evidence). We found an effect in favour of more time in rehabilitation for motor impairment measures of the upper limb (SMD 0.32, 95% CI 0.06 to 0.58; P = 0.01; I2 = 10%; 9 studies, 287 participants; low-certainty evidence) and of the lower limb (SMD 0.71, 95% CI 0.15 to 1.28; P = 0.01; 1 study, 51 participants; very low-certainty evidence). There were no intervention-related SAEs. More time in rehabilitation did not affect the risk of SAEs/death (RR 1.20, 95% CI 0.51 to 2.85; P = 0.68; I2 = 0%; 2 studies, 379 participants; low-certainty evidence), but few studies measured these outcomes. Predefined subgroup analyses comparing studies with a larger difference of total time spent in rehabilitation between intervention groups to studies with a smaller difference found greater improvements for studies with a larger difference. This was statistically significant for ADL outcomes (P = 0.02) and activity measures of the upper limb (P = 0.04), but not for activity measures of the lower limb (P = 0.41) or motor impairment measures of the upper limb (P = 0.06).

AUTHORS' CONCLUSIONS

An increase in time spent in the same type of rehabilitation after stroke results in little to no difference in meaningful activities such as activities of daily living and activities of the upper and lower limb but a small benefit in measures of motor impairment (low- to very low-certainty evidence for all findings). If the increase in time spent in rehabilitation exceeds a threshold, this may lead to improved outcomes. There is currently insufficient evidence to recommend a minimum beneficial daily amount in clinical practice. The findings of this study are limited by a lack of studies with a significant contrast in amount of additional rehabilitation provided between control and intervention groups. Large, well-designed, high-quality RCTs that measure time spent in all rehabilitation activities (not just interventional) and provide a large contrast (minimum of 1000 minutes) in amount of rehabilitation between groups would provide further evidence for effect of time spent in rehabilitation.

Effects of different rehabilitation provision systems on functional recovery in patients with subacute stroke

INTRODUCTION

The extent of rehabilitation is a key element in promoting functional recovery in patients with stroke. However, the type of rehabilitation therapy that should be provided to improve functional outcomes remains unclear.

OBJECTIVE

This study aimed to compare the effects of three different rehabilitation provision systems, namely conventional rehabilitation therapy, conventional rehabilitation therapy plus physical therapy (PT) on weekends, and conventional rehabilitation therapy plus PT and occupational therapy (OT) on weekends, on functional recovery in patients with subacute stroke.

DESIGN

Retrospective observational cohort study.

SETTING

Convalescence Rehabilitation Hospital.

PATIENTS

Three hundred and one patients with subacute stroke (mean age, 69.7 ± 12.8 years).

INTERVENTIONS

Patients were classified into three groups according to rehabilitation therapy they received: a conventional group (only weekdays PT and OT; n = 70), an additional PT group (additional PT on weekends; n = 119), and an additional PT + OT group (additional PT and OT on weekends; n = 112).

MAIN OUTCOME MEASURE

Functional Independence Measure (FIM) effectiveness was calculated as (discharge FIM - admission FIM/maximum FIM - admission FIM) × 100. A multivariate general linear model was used to assess the difference in FIM effectiveness among the groups.

RESULTS

The mean FIM effectiveness in the conventional, additional PT, and additional PT + OT groups were 39.3 ± 30.1, 43.4 ± 33.2, and 54.3 ± 29.1, respectively. The multivariate analysis revealed a significant difference in FIM effectiveness among the three groups (P = 0.036), and the η_p ² was 0.02, indicating a small effect. The additional PT + OT group showed significantly greater improvements in FIM effectiveness than the conventional group (mean difference = 8.78, SE = 3.58, 95% confidence interval: 0.17-17.39).

CONCLUSIONS

This study showed that the additional PT + OT group had better functional recovery than did the conventional group. This indicates that increasing the amount of both PT and OT can promote post-stroke functional recovery. This article is protected by copyright. All rights reserved.

Strengthening the Case for Cluster Set Resistance Training in Aged and Clinical Settings: Emerging Evidence, Proposed Benefits and Suggestions

Resistance training (RT) is a fundamental component of exercise prescription aimed at improving overall health and function. RT techniques such as cluster set (CS) configurations, characterized by additional short intra-set or inter-repetition rest intervals, have been shown to maintain acute muscular force, velocity, and 'power' outputs across a RT session, and facilitate positive longer-term neuromuscular adaptations. However, to date CS have mainly been explored from a human performance perspective despite potential for application in health and clinical exercise settings. Therefore, this current opinion piece aims to highlight emerging evidence and provide a rationale for why CS may be an advantageous RT technique for older adults, and across several neurological, neuromuscular, cardiovascular and pulmonary settings. Specifically, CS may minimize acute fatigue and adverse physiologic responses, improve patient tolerance of RT and promote functional adaptations (i.e., force, velocity, and power). Moreover, we propose that CS may be a particularly useful exercise rehabilitation technique where injury or illness, persistent fatigue, weakness and dysfunction exist. We further suggest that CS offer an alternative RT strategy that can be easily implemented alongside existing exercise/rehabilitation programs requiring no extra cost, minimal upskilling and/or time commitment for the patient and professional. In light of the emerging evidence and likely efficacy in clinical exercise practice, future research should move toward further direct investigation of CS-based RT in a variety of adverse health conditions and across the lifespan given the already demonstrated benefits in healthy populations.

Design and Preliminary Assessment of a Passive Elastic Leg Exoskeleton for Resistive Gait Rehabilitation

OBJECTIVE

This article aimed to develop a unique exoskeleton to provide different types of elastic resistances (i.e., resisting flexion, extension, or bidirectionally) to the leg muscles during walking.

METHODS

We created a completely passive leg exoskeleton, consisting of counteracting springs, pulleys, and clutches, to provide different types of elastic resistance to the knee. We first used a benchtop setting to calibrate the springs and validate the resistive capabilities of the device. We then tested the device's ability to alter gait mechanics, muscle activation, and kinematic aftereffects when walking on a treadmill under the three resistance types.

RESULTS

Benchtop testing indicated that the device provided a nearly linear torque profile and could be accurately configured to alter the angle where the spring system was undeformed (i.e., the resting position). Treadmill testing indicated the device could specifically target knee flexors, extensors, or both, and increase eccentric loading at the joint. Additionally, these resistance types elicited different kinematic aftereffects that could be used to target user-specific spatiotemporal gait deficits.

CONCLUSION

These results indicate that the elastic device can provide various types of targeted resistance training during walking.

SIGNIFICANCE

The proposed elastic device can provide a diverse set of resistance types that could potentially address user-specific muscle weaknesses and gait deficits through functional resistance training.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical activity and physical fitness are low after stroke. Interventions to increase physical fitness could reduce mortality and reduce disability through increased function.

OBJECTIVES

The primary objectives of this updated review were to determine whether fitness training after stroke reduces death, death or dependence, and disability. The secondary objectives were to determine the effects of training on adverse events, risk factors, physical fitness, mobility, physical function, health status and quality of life, mood, and cognitive function.

SEARCH METHODS

In July 2018 we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, and four additional databases. We also searched ongoing trials registers and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses and assessed the quality of the evidence using the GRADE approach. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 75 studies, involving 3017 mostly ambulatory participants, which comprised cardiorespiratory (32 studies, 1631 participants), resistance (20 studies, 779 participants), and mixed training interventions (23 studies, 1207 participants). Death was not influenced by any intervention; risk differences were all 0.00 (low-certainty evidence). There were few deaths overall (19/3017 at end of intervention and 19/1469 at end of follow-up). None of the studies assessed death or dependence as a composite outcome. Disability scores were improved at end of intervention by cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% CI 0.19 to 0.84; 8 studies, 462 participants; P = 0.002; moderate-certainty evidence) and mixed training (SMD 0.23, 95% CI 0.03 to 0.42; 9 studies, 604 participants; P = 0.02; low-certainty evidence). There were too few data to assess the effects of resistance training on disability. Secondary outcomes showed multiple benefits for physical fitness (VO2 peak and strength), mobility (walking speed) and physical function (balance). These physical effects tended to be intervention-specific with the evidence mostly low or moderate certainty. Risk factor data were limited or showed no effects apart from cardiorespiratory fitness (VO2 peak), which increased after cardiorespiratory training (mean difference (MD) 3.40 mL/kg/min, 95% CI 2.98 to 3.83; 9 studies, 438 participants; moderate-certainty evidence). There was no evidence of any serious adverse events. Lack of data prevents conclusions about effects of training on mood, quality of life, and cognition. Lack of data also meant benefits at follow-up (i.e. after training had stopped) were unclear but some mobility benefits did persist. Risk of bias varied across studies but imbalanced amounts of exposure in control and intervention groups was a common issue affecting many comparisons.

AUTHORS' CONCLUSIONS

Few deaths overall suggest exercise is a safe intervention but means we cannot determine whether exercise reduces mortality or the chance of death or dependency. Cardiorespiratory training and, to a lesser extent mixed training, reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve fitness, balance and the speed and capacity of walking. The magnitude of VO2 peak increase after cardiorespiratory training has been suggested to reduce risk of stroke hospitalisation by ˜7%. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription, the range of benefits and any long-term benefits.

Extra upper limb practice after stroke: a feasibility study

Background

There is a need to provide a large amount of extra practice on top of usual rehabilitation to adults after stroke. The purpose of this study was to determine if it is feasible to add extra upper limb practice to usual inpatient rehabilitation and whether it is likely to improve upper limb activity and grip strength.

Method

A prospective, single-group, pre- and post-test study was carried out. Twenty adults with upper limb activity limitations who had some movement in the upper limb completed an extra hour of upper limb practice, 6 days per week for 4 weeks. Feasibility was measured by examining recruitment, intervention (adherence, efficiency, acceptability, safety) and measurement. Clinical outcomes were upper limb activity (Box and Block Test, Nine-Hole Peg Test) and grip strength (dynamometry) measured at baseline (week 0) and end of intervention (week 4).

Results

Of the 212 people who were screened, 42 (20%) were eligible and 20 (9%) were enrolled. Of the 20 participants, 12 (60%) completed the 4-week program; 7 (35%) were discharged early, and 1 (5%) withdrew. Participants attended 342 (85%) of the possible 403 sessions and practiced for 324 (95%) of the total 342 h. In terms of safety, there were no study-related adverse events. Participants increased 0.29 blocks/s (95% CI 0.19 to 0.39) on the Box and Block Test, 0.20 pegs/s (95% CI 0.10 to 0.30) on the Nine-Hole Peg Test, and 4.4 kg (95% CI 2.9 to 5.9) in grip strength, from baseline to end of intervention.

Conclusions

It appears feasible for adults who are undergoing inpatient rehabilitation and have some upper limb movement after stroke to undertake an hour of extra upper limb practice. The magnitude of the clinical outcomes suggests that further investigation is warranted and this study provides useful information for the design of a phase II randomized trial.

Trial registration

Australian and New Zealand Clinical Trial Registry (ACTRN12615000665538).

Cost-effectiveness of physical fitness training for stroke survivors

Background Physical fitness is impaired after stroke, yet fitness training after stroke reduces disability. Several international guidelines recommend that fitness training be incorporated as part of stroke rehabilitation. However, information about cost-effectiveness is limited. Methods A decision tree model was used to estimate the cost-effectiveness of a fitness programme for stroke survivors vs. relaxation (control group). This was based on a published randomised controlled trial, from which evidence about quality of life was used to estimate Quality Adjusted Life Years. Costs were based on the cost of the provision of group fitness classes within local community centres and a cost per Quality Adjusted Life Year was calculated. Results The results of the base case analysis found an incremental cost per Quality Adjusted Life Year of £2,343. Conclusions Physical fitness sessions after stroke are a cost-effective intervention for stroke survivors. This information will help make the case for the development of new services.

Neuromechanical Differences Between Successful and Failed Sit-to-Stand Movements and Response to Rehabilitation Early After Stroke

BACKGROUND

Recovery of the sit-to-stand (StS) movement early after stroke could be improved by targeting physical therapy at the underlying movement deficits in those people likely to respond.

AIM

To compare the movement characteristics of successful and failed StS movements in people early after stroke and identify which characteristics change in people recovering their ability to perform this movement independently following rehabilitation.

METHODS

Muscle activity and kinematic (including center of mass, CoM) data were recorded from 91 participants (mean 35 days after stroke) performing the StS movement before (baseline), immediately after (outcome), and 3 months after (follow-up) rehabilitation. Three subgroups (never-able [n = 19], always-able [n = 51], and able-after-baseline [n = 21]) were compared at baseline with the able-after-baseline subgroup compared before and after rehabilitation.

RESULTS

The subgroups differed at baseline for quadriceps onset time ( P = .009) and forward body position when quadriceps peaked ( P = .038). Following rehabilitation, the able-after-baseline subgroup increased their forward position ( P < .001), decreased the time difference between bilateral quadriceps peaks ( P < .001) and between quadriceps and hamstrings peaks on the nonhemiplegic side ( P = .007). An improved performance in the always-able subgroup was associated with a number of baseline factors, including forward positioning ( P = .002) and time difference between peak activity of bilateral quadriceps ( P = .001).

CONCLUSIONS

This neuromechanical study of StS before and after rehabilitation in a sample of people early after stroke identified the importance of temporal coupling between forward trunk movement and quadriceps and hamstrings' activity. These findings advance the science of stroke rehabilitation by providing evidence-based therapy targets to promote recovery of the StS movement.

Ergometer cycling improves the ambulatory function and cardiovascular fitness of stroke patients-a randomized controlled trial

[Purpose] The aim of this study was to assess the effects of ergometer cycling on the ambulatory function and cardiovascular fitness of patients with stroke in the sub-acute phase. [Participants and Methods] Twenty (20) patients with stroke in the sub-acute phase were randomly allocated to either an ergometer cycling group (n=10) or a control group (n=10). The experimental (ergometer cycling) group performed cycling exercises in addition to conventional physiotherapy for 60 minutes per session, three times per week for 8 weeks. The control group only received conventional physiotherapy for the same duration as the experimental group. Assessments of participants’ functional ambulatory category, ambulatory velocity, 6-minute walk test, heart rate and blood pressure were conducted at baseline and at the end of the 8-week intervention. [Results] The means of the ambulatory velocity and distance walked in 6 minutes were significantly higher in the ergometer cycling group than those of the control group at week 8. However, the increase in the FAC score was not significant. The means of heart rate, systolic and diastolic blood pressures significantly decreased in the ergometer cycling group compared to the control group at the end of the 8-week of intervention. [Conclusion] This study demonstrated that ergometer cycling improved the ambulatory function and cardiovascular fitness of patients with stroke in the sub-acute phase.

Clinical education alone is sufficient to increase resistance training exercise prescription

A large body of evidence demonstrates that resistance training has been ineffective for improving walking outcomes in adults with neurological conditions. However, evidence suggests that previous studies have not aligned resistance exercise prescription to muscle function when walking. The main aim of this study was to determine whether a training seminar for clinicians could improve knowledge of gait and align resistance exercise prescription to the biomechanics of gait and muscle function for walking. A training seminar was conducted at 12 rehabilitation facilities with 178 clinicians. Current practice, knowledge and barriers to exercise were assessed by observation and questionnaire prior to and immediately after the seminar, and at three-month follow-up. Additionally, post-seminar support and mentoring was randomly provided to half of the rehabilitation facilities using a cluster randomised controlled trial (RCT) design. The seminar led to significant improvements in clinician knowledge of the biomechanics of gait and resistance training, the amount of ballistic (t = -2.38; p = .04) and conventional (t = -2.30; p = .04) resistance training being prescribed. However, ongoing post-seminar support and mentoring was not associated with any additional benefits F(1, 9) = .05, p = .83, partial eta squared = .01. Further, improved exercise prescription occurred in the absence of any change to perceived barriers. The training seminar led to significant improvements in the time spent in ballistic and conventional resistance training. There was no further benefit obtained from the additional post-seminar support. The seminar led to improved knowledge and significantly greater time spent prescribing task-specific resistance exercises.

Effectiveness and Superiority of Rehabilitative Treatments in Enhancing Motor Recovery Within 6 Months Poststroke: A Systemic Review

OBJECTIVE

To investigate the effects of various rehabilitative interventions aimed at enhancing poststroke motor recovery by assessing their effectiveness when compared with no treatment or placebo and their superiority when compared with conventional training program (CTP).

DATA SOURCE

A literature search was based on 19 Cochrane reviews and 26 other reviews. We also updated the searches in PubMed up to September 30, 2017.

STUDY SELECTION

Randomized controlled trials associated with 18 experimented training programs (ETP) were included if they evaluated the effects of the programs on either upper extremity (UE) or lower extremity (LE) motor recovery among adults within 6 months poststroke; included ≥10 participants in each arm; and had an intervention duration of ≥10 consecutive weekdays.

DATA EXTRACTION

Four reviewers evaluated the eligibility and quality of literature. Methodological quality was assessed using the PEDro scale.

DATA SYNTHESIS

Among the 178 included studies, 129 including 7450 participants were analyzed in this meta-analysis. Six ETPs were significantly effective in enhancing UE motor recovery, with the standard mean differences (SMDs) and 95% confidence intervals outlined as follow: constraint-induced movement therapy (0.82, 0.45-1.19), electrostimulation (ES)-motor (0.42, 0.22-0.63), mirror therapy (0.71, 0.22-1.20), mixed approach (0.21, 0.01-0.41), robot-assisted training (0.51, 0.22-0.80), and task-oriented training (0.57, 0.16-0.99). Six ETPs were significantly effective in enhancing LE motor recovery: body-weight-supported treadmill training (0.27, 0.01-0.52), caregiver-mediated training (0.64, 0.20-1.08), ES-motor (0.55, 0.27-0.83), mixed approach (0.35, 0.15-0.54), mirror therapy (0.56, 0.13-1.00), and virtual reality (0.60, 0.15-1.05). However, compared with CTPs, almost none of the ETPs exhibited significant SMDs for superiority.

CONCLUSIONS

Certain experimented interventions were effective in enhancing poststroke motor recovery, but little evidence supported the superiority of experimented interventions over conventional rehabilitation.

Interventions involving repetitive practice improve strength after stroke: a systematic review

QUESTIONS

Do interventions involving repetitive practice improve strength after stroke? Are any improvements in strength accompanied by improvements in activity?

DESIGN

Systematic review of randomised trials with meta-analysis.

PARTICIPANTS

Adults who have had a stroke.

INTERVENTION

Any intervention involving repetitive practice compared with no intervention or a sham intervention.

OUTCOME MEASURES

The primary outcome was voluntary strength in muscles trained as part of the intervention. The secondary outcomes were measures of lower limb and upper limb activity.

RESULTS

Fifty-two studies were included. The overall SMD of repetitive practice on strength was examined by pooling post-intervention scores from 46 studies involving 1928 participants. The SMD of repetitive practice on strength when the upper and lower limb studies were combined was 0.25 (95% CI 0.16 to 0.34, I²=44%) in favour of repetitive practice. Twenty-four studies with a total of 912 participants investigated the effects of repetitive practice on upper limb activity after stroke. The SMD was 0.15 (95% CI 0.02 to 0.29, I²=50%) in favour of repetitive practice on upper limb activity. Twenty studies with a total of 952 participants investigated the effects of repetitive practice on lower limb activity after stroke. The SMD was 0.25 (95% CI 0.12 to 0.38, I²=36%) in favour of repetitive practice on lower limb activity.

CONCLUSION

Interventions involving repetitive practice improve strength after stroke, and these improvements are accompanied by improvements in activity.

REVIEW REGISTRATION

PROSPERO CRD42017068658. [de Sousa DG, Harvey LA, Dorsch S, Glinsky JV (2018) Interventions involving repetitive practice improve strength after stroke: a systematic review. Journal of Physiotherapy 64: 210-221].

A Portable Passive Rehabilitation Robot for Upper-Extremity Functional Resistance Training

OBJECTIVE

Loss of arm function is common in individuals with neurological damage, such as stroke or cerebral palsy. Robotic devices that address muscle strength deficits in a task-specific manner can assist in the recovery of arm function; however, current devices are typically large, bulky, and expensive to be routinely used in the clinic or at home. This study sought to address this issue by developing a portable planar passive rehabilitation robot, PaRRo.

METHODS

We designed PaRRo with a mechanical layout that incorporated kinematic redundancies to generate forces that directly oppose the user's movement. Cost-efficient eddy current brakes were used to provide scalable resistances. The lengths of the robot's linkages were optimized to have a reasonably large workspace for human planar reaching. We then performed theoretical analysis of the robot's resistive force generating capacity and steerable workspace using MATLAB simulations. We also validated the device by having a subject move the end-effector along different paths at a set velocity using a metronome while simultaneously collecting surface electromyography (EMG) and end-effector forces felt by the user.

RESULTS

Results from simulation experiments indicated that the robot was capable of producing sufficient end-effector forces for functional resistance training. We also found the endpoint forces from the user were similar to the theoretical forces expected at any direction of motion. EMG results indicated that the device was capable of providing adjustable resistances based on subjects' ability levels, as the muscle activation levels scaled with increasing magnet exposures.

CONCLUSION

These results indicate that PaRRo is a feasible approach to provide functional resistance training to the muscles along the upper extremity.

SIGNIFICANCE

The proposed robotic device could provide a technological breakthrough that will make rehabilitation robots accessible for small outpatient rehabilitation centers and in-home therapy.

Feasibility of Ballistic Strength Training in Subacute Stroke: A Randomized, Controlled, Assessor-Blinded Pilot Study

OBJECTIVE

To establish the feasibility and effectiveness of a 6-week ballistic strength training protocol in people with stroke.

DESIGN

Randomized, controlled, assessor-blinded study.

SETTING

Subacute inpatient rehabilitation.

PARTICIPANTS

Consecutively admitted inpatients with a primary diagnosis of first-ever stroke with lower limb weakness, functional ambulation category score of ≥3, and ability to walk ≥14 m were screened for eligibility to recruit 30 participants for randomization.

INTERVENTIONS

Participants were randomized to standard therapy or ballistic strength training 3 times per week for 6 weeks.

MAIN OUTCOME MEASURES

The primary aim was to evaluate feasibility and outcomes included recruitment rate, participant retention and attrition, feasibility of the exercise protocol, therapist burden, and participant safety. Secondary outcomes included measures of mobility, lower limb muscle strength, muscle power, and quality of life.

RESULTS

A total of 30 participants (11% of those screened) with mean age of 50 years (SD 18) were randomized. The median number of sessions attended was 15 of 18 and 17 of 18 for the ballistic and control groups, respectively. Earlier than expected discharge to home (n=4) and illness (n=7) were the most common reasons for nonattendance. Participants performed the exercises safely, with no study-related adverse events. There were significant (P<.05) between-group changes favoring the ballistic group for comfortable gait velocity (mean difference [MD] 0.31m/s, 95% confidence interval [CI]: 0.08-0.52), muscle power, as measured by peak jump height (MD 8cm, 95% CI: 3-13), and peak propulsive velocity (MD 64cm/s, 95% CI: 17-112).

CONCLUSIONS

Ballistic training was safe and feasible in select ambulant people with stroke. Similar rates of retention and attrition suggest that ballistic training was acceptable to patients. Secondary outcomes provide promising results that warrant further investigation in a larger trial.

Additional Physical Therapy Services Reduce Length of Stay and Improve Health Outcomes in People With Acute and Subacute Conditions: An Updated Systematic Review and Meta-Analysis

OBJECTIVE

To update a previous review on whether additional physical therapy services reduce length of stay, improve health outcomes, and are safe and cost-effective for patients with acute or subacute conditions.

DATA SOURCES

Electronic database (AMED, CINAHL, EMBASE, MEDLINE, Physiotherapy Evidence Database [PEDro], PubMed) searches were updated from 2010 through June 2017.

STUDY SELECTION

Randomized controlled trials evaluating additional physical therapy services on patient health outcomes, length of stay, or cost-effectiveness were eligible. Searching identified 1524 potentially relevant articles, of which 11 new articles from 8 new randomized controlled trials with 1563 participants were selected. In total, 24 randomized controlled trials with 3262 participants are included in this review.

DATA EXTRACTION

Data were extracted using the form used in the original systematic review. Methodological quality was assessed using the PEDro scale, and the Grading of Recommendation Assessment, Development, and Evaluation approach was applied to each meta-analysis.

DATA SYNTHESIS

Postintervention data were pooled with an inverse variance, random-effects model to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). There is moderate-quality evidence that additional physical therapy services reduced length of stay by 3 days in subacute settings (mean difference [MD]=-2.8; 95% CI, -4.6 to -0.9; I²=0%), and low-quality evidence that it reduced length of stay by 0.6 days in acute settings (MD=-0.6; 95% CI, -1.1 to 0.0; I²=65%). Additional physical therapy led to small improvements in self-care (SMD=.11; 95% CI, .03-.19; I²=0%), activities of daily living (SMD=.13; 95% CI, .02-.25; I²=15%), and health-related quality of life (SMD=.12; 95% CI, .03-.21; I²=0%), with no increases in adverse events. There was no significant change in walking ability. One trial reported that additional physical therapy was likely to be cost-effective in subacute rehabilitation.

CONCLUSIONS

Additional physical therapy services improve patient activity and participation outcomes while reducing hospital length of stay for adults. These benefits are likely safe, and there is preliminary evidence to suggest they may be cost-effective.

Functional Strength Training and Movement Performance Therapy for Upper Limb Recovery Early Poststroke-Efficacy, Neural Correlates, Predictive Markers, and Cost-Effectiveness: FAST-INdiCATE Trial

BACKGROUND

Variation in physiological deficits underlying upper limb paresis after stroke could influence how people recover and to which physical therapy they best respond.

OBJECTIVES

To determine whether functional strength training (FST) improves upper limb recovery more than movement performance therapy (MPT). To identify: (a) neural correlates of response and (b) whether pre-intervention neural characteristics predict response.

DESIGN

Explanatory investigations within a randomised, controlled, observer-blind, and multicentre trial. Randomisation was computer-generated and concealed by an independent facility until baseline measures were completed. Primary time point was outcome, after the 6-week intervention phase. Follow-up was at 6 months after stroke.

PARTICIPANTS

With some voluntary muscle contraction in the paretic upper limb, not full dexterity, when recruited up to 60 days after an anterior cerebral circulation territory stroke.

INTERVENTIONS

Conventional physical therapy (CPT) plus either MPT or FST for up to 90 min-a-day, 5 days-a-week for 6 weeks. FST was "hands-off" progressive resistive exercise cemented into functional task training. MPT was "hands-on" sensory/facilitation techniques for smooth and accurate movement.

OUTCOMES

The primary efficacy measure was the Action Research Arm Test (ARAT). Neural measures: fractional anisotropy (FA) corpus callosum midline; asymmetry of corticospinal tracts FA; and resting motor threshold (RMT) of motor-evoked potentials.

ANALYSIS

Covariance models tested ARAT change from baseline. At outcome: correlation coefficients assessed relationship between change in ARAT and neural measures; an interaction term assessed whether baseline neural characteristics predicted response.

RESULTS

288 Participants had: mean age of 72.2 (SD 12.5) years and mean ARAT 25.5 (18.2). For 240 participants with ARAT at baseline and outcome the mean change was 9.70 (11.72) for FST + CPT and 7.90 (9.18) for MPT + CPT, which did not differ statistically (p = 0.298). Correlations between ARAT change scores and baseline neural values were between 0.199, p = 0.320 for MPT + CPT RMT (n = 27) and -0.147, p = 0.385 for asymmetry of corticospinal tracts FA (n = 37). Interaction effects between neural values and ARAT change between baseline and outcome were not statistically significant.

CONCLUSIONS

There was no significant difference in upper limb improvement between FST and MPT. Baseline neural measures did not correlate with upper limb recovery or predict therapy response.

TRIAL REGISTRATION

Current Controlled Trials: ISRCT 19090862, http://www.controlled-trials.com.

Is there a relationship between postural alignment and mobility for adults after acquired brain injury? A systematic review

PRIMARY OBJECTIVE

To examine the relationship between postural alignment and mobility skills for adults after acquired brain injury (ABI).

METHODS

Systematic review of the literature. Seven electronic databases, grey literature and reference lists of the shortlisted publications were searched. Studies were included if participants were adults with ABI, both postural alignment and mobility were measured and analysis included a relationship between alignment and mobility. Those that met the inclusion criteria were assessed with a critical appraisal tool. The review was registered with PROSPERO, registration number CRD42015019867.

RESULTS

Seven observational studies were included that had examined a relationship between postural alignment and mobility after ABI. Critical appraisal scores were moderate to strong. While some studies reported that improved postural alignment was related to improved mobility after ABI, results varied and there was insufficient evidence to answer the primary question. Heterogeneous study designs did not allow meta-regression.

CONCLUSIONS

A small amount of observational evidence exists for a relationship between postural alignment and mobility after ABI. Results vary, with some studies reporting that a more stable, upright trunk correlates with better mobility, and others providing conflicting or ambiguous results. Further research is needed to establish the relationship between postural alignment and mobility skills after ABI.

Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review

QUESTIONS

In people receiving rehabilitation aimed at reducing activity limitations of the lower and/or upper limb after stroke, does adding extra rehabilitation (of the same content as the usual rehabilitation) improve activity? What is the amount of extra rehabilitation that needs to be provided to achieve a beneficial effect?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Adults aged 18 years or older that had a diagnosis of stroke.

INTERVENTION

Extra rehabilitation with the same content as usual rehabilitation aimed at reducing activity limitations of the lower and/or upper limb.

OUTCOME MEASURES

Activity measured as lower or upper limb ability.

RESULTS

A total of 14 studies, comprising 15 comparisons, met the inclusion criteria. Pooling data from all the included studies showed that extra rehabilitation improved activity immediately after the intervention period (SMD=0.39, 95% CI 0.07 to 0.71, I(2)=66%). When only studies with a large increase in rehabilitation (> 100%) were included, the effect was greater (SMD 0.59, 95% CI 0.23 to 0.94, I(2)=44%). There was a trend towards a positive relationship (r=0.53, p=0.09) between extra rehabilitation and improved activity. The turning point on the ROC curve of false versus true benefit (AUC=0.88, p=0.04) indicated that at least an extra 240% of rehabilitation was needed for significant likelihood that extra rehabilitation would improve activity.

CONCLUSION

Increasing the amount of usual rehabilitation aimed at reducing activity limitations improves activity in people after stroke. The amount of extra rehabilitation that needs to be provided to achieve a beneficial effect is large.

TRIAL REGISTRATION

PROSPERO CRD42012003221. [Schneider EJ, Lannin NA, Ada L, Schmidt J (2016) Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review.Journal of Physiotherapy62: 182-187].

Physical fitness training for stroke patients

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.

Functional strength training and movement performance therapy produce analogous improvement in sit-to-stand early after stroke: early-phase randomised controlled trial

OBJECTIVES

Restoring independence in the sit-to-stand (STS) task is an important objective for stroke rehabilitation. It is not known if a particular intervention, strength training or therapy focused on movement performance is more likely to improve STS recovery. This study aimed to compare STS outcomes from functional strength training, movement performance therapy and conventional therapy.

DESIGN

Randomised controlled trial.

SETTING

Acute stroke units.

PARTICIPANTS

Medically well patients (n=93) with recent (<42 days) stroke. The mean age of patients was 68.8 years, mean time post ictus was 33.5 days, 54 (58%) were male, 20 showed neglect (22%) and 37 (40%) had a left-sided brain lesion.

INTERVENTIONS

Six weeks of either conventional therapy, functional strength training or movement performance therapy. Subjects were allocated to groups on a random basis.

MAIN OUTCOME MEASURES

STS ability, timing, symmetry, co-ordination, smoothness and knee velocity were measured at baseline, outcome (after 6 weeks of intervention) and follow-up (3 months after outcome).

RESULTS

No significant differences were found between the groups. All three groups improved their STS ability, with 88% able to STS at follow-up compared with 56% at baseline. Few differences were noted in quality of movement, with only symmetry when rising showing significantly greater improvement in the movement performance therapy group; this benefit was not evident at follow-up.

CONCLUSIONS

Recovery of the STS movement is consistently good during stroke rehabilitation, irrespective of the type of therapy experienced. Changes in quality of movement did not differ according to group allocation, indicating that the type of therapy is less important. Clinical trial registration number NCT00322192.

A Randomized Controlled Evaluation of the Efficacy of an Ankle-Foot Cast on Walking Recovery Early After Stroke: SWIFT Cast Trial

Background. Timely provision of an ankle-foot orthosis (AFO) orthotist customized for individuals early after stroke can be problematic. Objective. To evaluate the efficacy of a therapist-made AFO (SWIFT Cast) for walking recovery. Methods. This was a randomized controlled, observer-blind trial. Participants (n = 105) were recruited 3 to 42 days poststroke. All received conventional physical therapy (CPT) that included use of “off-the-shelf” and orthotist-made AFOs. People allocated to the experimental group also received a SWIFT Cast for up to 6 weeks. Measures were undertaken before randomization, 6 weeks thereafter (outcome), and at 6 months after stroke (follow-up). The primary measure was walking speed. Clinical efficacy evaluation used analysis of covariance. Results. Use of a SWIFT Cast during CPT sessions was significantly higher (P < .001) for the SWIFT Cast (55%) than the CPT group (3%). The CPT group used an AFO in 26% of CPT sessions, compared with 11% for the SWIFT Cast group (P = .005). At outcome, walking speed was 0.42 (standard deviation [SD] = 0.37) m/s for the CPT group and 0.32 (SD = 0.34) m/s for the SWIFT Cast group. Follow-up walking speed was 0.53 (SD = 0.38) m/s for the CPT group and 0.43 (0.34) m/s for the SWIFT Cast group. Differences, after accounting for minimization factors, were insignificant at outcome (P = .345) and follow-up (P = .360). Conclusion and implications. SWIFT Cast did not enhance the benefit of CPT, but the control group had greater use of another AFO. However, SWIFT Cast remains a clinical option because it is low cost and custom-made by therapists who can readily adapt it during the rehabilitation period.

Brain Activity during Lower-Limb Movement with Manual Facilitation: An fMRI Study

Brain activity knowledge of healthy subjects is an important reference in the context of motor control and reeducation. While the normal brain behavior for upper-limb motor control has been widely explored, the same is not true for lower-limb control. Also the effects that different stimuli can evoke on movement and respective brain activity are important in the context of motor potentialization and reeducation. For a better understanding of these processes, a functional magnetic resonance imaging (fMRI) was used to collect data of 10 healthy subjects performing lower-limb multijoint functional movement under three stimuli: verbal stimulus, manual facilitation, and verbal + manual facilitation. Results showed that, with verbal stimulus, both lower limbs elicit bilateral cortical brain activation; with manual facilitation, only the left lower limb (LLL) elicits bilateral activation while the right lower limb (RLL) elicits contralateral activation; verbal + manual facilitation elicits bilateral activation for the LLL and contralateral activation for the RLL. Manual facilitation also elicits subcortical activation in white matter, the thalamus, pons, and cerebellum. Deactivations were also found for lower-limb movement. Manual facilitation is stimulus capable of generating brain activity in healthy subjects. Stimuli need to be specific for bilateral activation and regarding which brain areas we aim to activate.

[Intensity in the neurorehabilitation of spastic paresis]

Neurorestoration of motor command in spastic paresis requires a double action of stimulation and guidance of central nervous system plasticity. Beyond drug therapies, electrical stimulation and cell therapies, which may stimulate plasticity without precisely guiding it, two interventions seem capable of driving plasticity with a double stimulation and guidance component: the lesion itself (lesion-induced plasticity) and durable behavior modifications (behavior-induced plasticity). Modern literature makes it clear that the intensity of the neuronal and physical training is a primary condition to foster behavior-induced plasticity. When it comes to working on movement, intensity can be achieved by the combination of two key components, one is the difficulty of the trained movement, the other is the number of repetitions or the daily duration of the practice. A number of recent studies shed light on promising recovery prospects, particularly using the emergence of new technologies such as robot-assisted therapy and concepts such as guided self-rehabilitation contracts.

Strength training for walking in neurologic rehabilitation is not task specific: a focused review

The aim of this systematic review was to investigate the task specificity of strength training programs for walking in neurologic rehabilitation. Nine electronic databases were searched from conception to October 2012 for randomized controlled trials that used strength training to improve walking in adult neurologic populations. The search identified 25 randomized controlled trials that investigated the efficacy of strength training to improve walking in people with a variety of neurologic conditions. The results revealed that despite significant strength gains, many studies failed to show a significant improvement in walking capacity. Most studies did not include exercises relating to all three main power events important for walking. Strength testing and strengthening exercises were prioritized for the knee extensors and flexors, despite their relatively minor role in human walking. Strengthening exercises performed in the neurologic population are not specific to the main muscle groups responsible for the power generation required for walking. There is a predisposition for strength testing and strengthening exercises to focus on the knee flexors and extensors despite their relatively minor role during walking. Further consideration of the specificity of strength training may provide greater translation of strength gains to improved walking outcomes.

Circuit Class Therapy and 7-Day-Week Therapy Increase Physiotherapy Time, But Not Patient Activity

Background and Purpose—

The optimum model of physiotherapy service delivery for maximizing active task practice during rehabilitation after stroke is unknown. The purpose of the study was to examine the relative effectiveness of 2 alternative models of physiotherapy service delivery against a usual care control with regard to increasing patient activity.

Methods—

Substudy within a large 3-armed randomized controlled trial, which compared 3 different models of physiotherapy service delivery, was provided for 4 weeks during subacute, inpatient rehabilitation (n=283). The duration of all physiotherapy sessions was recorded. In addition, 32 participants were observed at 10-minute intervals for 1 weekday and 1 weekend day between 8:00 am and 4:30 pm . At each observation, we recorded physical activity, location, and people present.

Results—

Participants receiving 7-day-week and circuit class therapy received an additional 3 hours and 22 hours of physiotherapy time, respectively, when compared with usual care. Participants were standing or walking for a median of 8.2% of observations. On weekdays, circuit class therapy participants spent more time in therapy-related activity (10.2% of observations) when compared with usual care participants (6.1% of observations). On weekends, 7-day therapy participants spent more time in therapy-related activity (4.2% of observations) when compared with both usual care and circuit class therapy participants (0% of observations for both groups). Activity levels outside of therapy sessions did not differ between groups.

Conclusions—

A greater dosage of physiotherapy time did not translate into meaningful increases in physical activity across the day.

Clinical Trial Registration—

URL: http://www.anzctr.org.au/ . Unique identifier: ACTRN12610000096055.

Feasibility of a randomized controlled trial of functional strength training for people between six months and five years after stroke: FeSTivaLS trial

BACKGROUND

Functional Strength Training (FST) could enhance recovery late after stroke. The aim of this study was to evaluate the feasibility of a subsequent fully powered, randomized controlled trial.

METHODS

The study was designed as a randomized, observer-blind trial. Both interventions were provided for up to one hour a day, four days a week, for six weeks. Evaluation points were before randomization (baseline), after six weeks intervention (outcome), and six weeks thereafter (follow-up). The study took place in participants' own homes. Participants (n = 52) were a mean of 24.4 months after stroke with a mean age of 68.3 years with 67.3% male. All had difficulty using their paretic upper (UL) and lower limb (LL). Participants were allocated to FST-UL or FST-LL by an independent randomization service. The outcome measures were recruitment rate, attrition rate, practicality of recruitment strategies, occurrence of adverse reactions, acceptability of FST, and estimation of sample size for a subsequent trial. Primary clinical efficacy outcomes were the Action Research Arm Test (ARAT) and the Functional Ambulation Categories (FAC). Analysis was conducted using descriptive statistics and thematic analysis of participants' views of FST. A power calculation used estimates of clinical efficacy variance to estimate sample size for a subsequent trial.

RESULTS

The screening process identified 1,127 stroke survivors of whom 52 (4.6%) were recruited. The recruitment rate was higher for referral from community therapists than for systematic identification of people discharged from an acute stroke unit. The attrition rate was 15.5% at the outcome and follow-up time-points. None of the participants experienced an adverse reaction. The participants who remained in the study at outcome had received 68% of the total possible amount of therapy. Participants reported that their experience of FST provided a sense of purpose and involvement and increased their confidence in performing activities. The power calculation provides estimation that 150 participants in each group will be required for a subsequent clinical trial.

CONCLUSIONS

This study found that a subsequent clinical trial was feasible with modifications to the recruitment strategy to be used.

TRIAL REGISTRATION

Controlled-trials.com ISCTN71632550, 30 January 2009.

Is more better? Using metadata to explore dose-response relationships in stroke rehabilitation

BACKGROUND AND PURPOSE

Neurophysiological models of rehabilitation and recovery suggest that a large volume of specific practice is required to induce the neuroplastic changes that underlie behavioral recovery. The primary objective of this meta-analysis was to explore the relationship between time scheduled for therapy and improvement in motor therapy for adults after stroke by (1) comparing high doses to low doses and (2) using metaregression to quantify the dose-response relationship further.

METHODS

Databases were searched to find randomized controlled trials that were not dosage matched for total time scheduled for therapy. Regression models were used to predict improvement during therapy as a function of total time scheduled for therapy and years after stroke.

RESULTS

Overall, treatment groups receiving more therapy improved beyond control groups that received less (g=0.35; 95% confidence interval, 0.26-0.45). Furthermore, increased time scheduled for therapy was a significant predictor of increased improvement by itself and when controlling for linear and quadratic effects of time after stroke.

CONCLUSIONS

There is a positive relationship between the time scheduled for therapy and therapy outcomes. These data suggest that large doses of therapy lead to clinically meaningful improvements, controlling for time after stroke. Currently, trials report time scheduled for therapy as a measure of therapy dose. Preferable measures of dose would be active time in therapy or repetitions of an exercise.

Physical rehabilitation approaches for the recovery of function and mobility following stroke

BACKGROUND

Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches.

OBJECTIVES

To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.For the previous versions of this review, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate individual treatment components, categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches.

DATA COLLECTION AND ANALYSIS

Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data.

MAIN RESULTS

We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions.

AUTHORS' CONCLUSIONS

Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.

Physical rehabilitation approaches for the recovery of function and mobility following stroke

BACKGROUND

Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches.

OBJECTIVES

To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.For the previous versions of this review, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate individual treatment components, categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches.

DATA COLLECTION AND ANALYSIS

Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data.

MAIN RESULTS

We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions.

AUTHORS' CONCLUSIONS

Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.

What is the evidence for physical therapy poststroke? A systematic review and meta-analysis

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.

Physical fitness training for stroke patients

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.

Stroke rehabilitation: recent advances and future therapies

Despite advances in the acute management of stroke, a large proportion of stroke patients are left with significant impairments. Over the coming decades the prevalence of stroke-related disability is expected to increase worldwide and this will impact greatly on families, healthcare systems and economies. Effective neuro-rehabilitation is a key factor in reducing disability after stroke. In this review, we discuss the effects of stroke, principles of stroke rehabilitative care and predictors of recovery. We also discuss novel therapies in stroke rehabilitation, including non-invasive brain stimulation, robotics and pharmacological augmentation. Many trials are currently underway, which, in time, may impact on future rehabilitative practice.

Observation-to-Imitate Plus Practice Could Add Little to Physical Therapy Benefits Within 31 Days of Stroke

Background and Purpose. Observation of action with intention-to-imitate (OTI) might enhance motor recovery. This early phase trial investigated whether OTI followed by physical practice (OTI + PP) enhanced the benefits of conventional physical therapy (CPT) on upper limb recovery early after stroke. Methods. Participants were 3 to 31 days poststroke. They had substantial paresis and ability to imitate action with their ipsilesional arm. After baseline measures, participants were randomized to either OTI + PP in addition to CPT or to CPT only. Outcome measures were made after 15 days of treatment. The measurement battery was the Motricity Index (MI) and the Action Research Arm Test (ARAT). Change, baseline to outcome, was examined using the Wilcoxon test for within group and Mann–Whitney U test for between groups. Results. Sixty-five of 570 stroke survivors were eligible, 55 were able to imitate, 37 gave informed consent, 7 were transferred out of area before baseline, and 29 were randomized. Outcome measures were completed with 13 CPT participants and 9 OTI + PP participants. Both groups showed statistically significant improvements for the MI (CPT median change 8, P = .003; OTI + PP median change 10, P = .012) but the median (95% confidence interval [CI]) between-group difference was 0.0 (−11, 16), P = 1.000. For the ARAT, only the CPT group showed a statistically significant improvement (median 9, P = .006). The median (95% CI) between-group difference of 1.0 (−18, 23) was not statistically significant ( P = .815). Conclusions. These findings suggest that OTI + PP might add little to the benefits of CPT early after stroke.

The FeSTivaLS trial protocol: a randomized evaluation of the efficacy of functional strength training on enhancing walking and upper limb function later post stroke

RATIONALE

Functional Strength Training may enhance motor function of people who are more than six months post stroke.

AIMS

to evaluate the clinical efficacy of enhancing upper and lower limb motor function with FST to explore participants' views (expectations and experiences) of FST, and to determine what cost-effectiveness data to collect in a subsequent Phase III trial.

DESIGN

Randomized, observer-blind trial with embedded qualitative investigation of participants' views of FST (n = 6, purposive sampling).

STUDY

Participants (n = 58), six months to five years after stroke with difficulty using their paretic upper (UL) and lower limbs (LL) for everyday functional activity. All will be randomized to either FST-UL or FST-LL delivered in their own homes for four days each week for six weeks. FST involves repetitive progressive resisted exercise during goal directed functional activities. The therapist's main input is to provide verbal prompting and feedback.

OUTCOMES

Measures will be undertaken before randomization (baseline), after the six-week intervention (outcome) and six weeks thereafter (follow-up). Primary outcomes for clinical efficacy will be the Functional Ambulation Categories (FAC) and the Action Research Arm Test (ARAT). Clinical efficacy analysis will use the proportional odds model for FAC and a Mann-Whitney test for ARAT. Participants' views of FST will be explored at baseline and outcome through audiotaped, semi-structured, narrative approach, interviews. The analytic process for interviews will sort transcribed data thematically and seek categories to inform conceptualization (theory-building). A purpose-designed cost questionnaire will identify what cost resource items are likely to be affected by FST.