The Glasgow Augmented Physiotherapy Study (GAPS) group. Can augmented physiotherapy input enhance recovery of mobility after stroke? A randomized controlled trial

Interventions to Change Movement Behaviors After Stroke: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review aimed to determine which interventions increase physical activity (PA) and decrease sedentary behavior (SB) based on objective measures of movement behavior in individuals with stroke.

DATA SOURCES

The PubMed (Medline), EMBASE, Scopus, CINAHL (EBSCO), and Web of Science databases were searched for articles published up to January 3, 2023.

STUDY SELECTION

The StArt 3.0.3 BETA software was used to screen titles, abstracts, and full texts for studies with randomized controlled trial designs; individuals with stroke (≥18 years of age); interventions aimed at increasing PA or decreasing SB; and objective measurement instruments.

DATA EXTRACTION

Data extraction was standardized, considering participants and assessments of interest. The risk of bias and quality of evidence of the included studies were assessed.

DATA SYNTHESIS

Twenty-eight studies involving 1855 patients were included. Meta-analyses revealed that in the post-stroke acute/subacute phase, exercise interventions combined with behavior change techniques (BCTs) increased both daily steps (standardized mean difference [SMD]=0.65, P=.0002) and time spent on moderate-to-vigorous intensity physical activities (MVPAs) duration of PA (SMD=0.68, P=.0004) with moderate-quality evidence. In addition, interventions based only on BCTs increased PA levels with very low-quality evidence (SMD (low-intensity physical activity)=0.36, P=.02; SMD (MVPA)=0.56, P=.0004) and decreased SB with low-quality evidence (SMD=0.48, P=.03). In the post-stroke chronic phase, there is statistical significance in favor of exercise-only interventions in PA frequency (steps/day) with moderate-quality evidence (SMD=0.68, P=.002). In general, the risk of bias in the included studies was low.

CONCLUSIONS

In the acute/subacute phase after stroke, the use of BCTs combined with exercise can increase the number of daily steps and time spent on MVPA. In contrast, in the post-stroke chronic phase, exercise-only interventions resulted in a significant increase in daily steps.

Feasibility of a home-based physiotherapy intervention to promote post-stroke mobility: A randomized controlled pilot study

Objectives

Home-based physiotherapy interventions to improve post-stroke mobility are successful in high-income countries. These programs require less resources compared to center-based programs. However, feasibility of such an intervention in a low and middle-income setting remains unknown. Therefore, the SunRISe (Stroke Rehabilitation In Suriname) study aimed to assess feasibility and preliminary effectiveness of a home-based semi-supervised physiotherapy intervention to promote post-stroke mobility in a low resource setting.

Design

Prospective randomized controlled trial.

Methods

Chronic stroke patients were recruited and randomized into either an intervention group (IG (N = 20)) or a control group (CG (N = 10)). The IG received a 3-days-a-week home-based physiotherapy program that was supervised in the first 4 weeks and tele-supervised during the second 4 weeks. The physiotherapy program consisted of walking as well as functional and mobilization exercises. The CG received usual care. Feasibility outcome measures included adherence, patient satisfaction and safety. Efficacy measures included functional exercise tolerance (six-minute walking test (6MWT), functional balance (Berg Balance Score (BBS), upper extremity (UE) function (Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire), and UE strength ((non-)paretic handgrip (HG) strength). Two-way analysis of variance was used for data analysis.

Results

Thirty participants (61.8 ± 9.2 years old, 13 men) were enrolled in the study. The intervention was completed by 14 participants (70%). Adherence was affected by rainy season associated infrastructural problems (n = 2), the medical status of participants (n = 3) and insufficient motivation to continue the program without direct supervision (n = 1). No adverse events were noted and participants were satisfied with the program. Functional exercise tolerance (57.2 ± 67.3m, p = 0.02) and UE function (-9.8 ± 15.2, p = 0.04) improved in the IG compared to no change in the CG. HG strength was unaltered and a ceiling effect occurred for BBS.

Conclusion

Our home-based semi-supervised physiotherapy intervention seems safe, associated with moderate to high levels of engagement and patient satisfaction and results in functional improvements.

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.

Interventions for reducing sedentary behaviour in people with stroke

BACKGROUND

Stroke survivors are often physically inactive as well as sedentary,and may sit for long periods of time each day. This increases cardiometabolic risk and has impacts on physical and other functions. Interventions to reduce or interrupt periods of sedentary time, as well as to increase physical activity after stroke, could reduce the risk of secondary cardiovascular events and mortality during life after stroke.

OBJECTIVES

To determine whether interventions designed to reduce sedentary behaviour after stroke, or interventions with the potential to do so, can reduce the risk of death or secondary vascular events, modify cardiovascular risk, and reduce sedentary behaviour.

SEARCH METHODS

In December 2019, we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, Conference Proceedings Citation Index, and PEDro. We also searched registers of ongoing trials, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing interventions to reduce sedentary time with usual care, no intervention, or waiting-list control, attention control, sham intervention or adjunct intervention. We also included interventions intended to fragment or interrupt periods of sedentary behaviour.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and performed 'Risk of bias' assessments. We analyzed data using random-effects meta-analyses and assessed the certainty of the evidence with the GRADE approach.

MAIN RESULTS

We included 10 studies with 753 people with stroke. Five studies used physical activity interventions, four studies used a multicomponent lifestyle intervention, and one study used an intervention to reduce and interrupt sedentary behaviour. In all studies, the risk of bias was high or unclear in two or more domains. Nine studies had high risk of bias in at least one domain. The interventions did not increase or reduce deaths (risk difference (RD) 0.00, 95% confidence interval (CI) -0.02 to 0.03; 10 studies, 753 participants; low-certainty evidence), the incidence of recurrent cardiovascular or cerebrovascular events (RD -0.01, 95% CI -0.04 to 0.01; 10 studies, 753 participants; low-certainty evidence), the incidence of falls (and injuries) (RD 0.00, 95% CI -0.02 to 0.02; 10 studies, 753 participants; low-certainty evidence), or incidence of other adverse events (moderate-certainty evidence). Interventions did not increase or reduce the amount of sedentary behaviour time (mean difference (MD) +0.13 hours/day, 95% CI -0.42 to 0.68; 7 studies, 300 participants; very low-certainty evidence). There were too few data to examine effects on patterns of sedentary behaviour. The effect of interventions on cardiometabolic risk factors allowed very limited meta-analysis.

AUTHORS' CONCLUSIONS

Sedentary behaviour research in stroke seems important, yet the evidence is currently incomplete, and we found no evidence for beneficial effects. Current World Health Organization (WHO) guidelines recommend reducing the amount of sedentary time in people with disabilities, in general. The evidence is currently not strong enough to guide practice on how best to reduce sedentariness specifically in people with stroke. More high-quality randomised trials are needed, particularly involving participants with mobility limitations. Trials should include longer-term interventions specifically targeted at reducing time spent sedentary, risk factor outcomes, objective measures of sedentary behaviour (and physical activity), and long-term follow-up.

Early-phase dose articulation trials are underutilized for post-stroke motor recovery: A systematic scoping review

BACKGROUND

To enable development of effective interventions, there is a need to complete systematic early-phase dose articulation research. This scoping review aimed to synthesize dose articulation research of behavioral motor interventions for stroke recovery.

METHODS

MEDLINE and EMBASE were systematically searched for dose articulation studies. Preclinical experiments and adult clinical trials were classified based on the discovery pipeline and analyzed to determine which dose dimensions were articulated (time, scheduling or intensity) and how they were investigated (unidimensional vs multidimensional approach). Reporting of dose, safety and efficacy outcomes were summarized. The intervention description, risk of bias, and quality was appraised.

RESULTS

We included 41 studies: 3 of preclinical dose preparation (93 rodents), 2 Phase I dose ranging (21 participants), 9 Phase IIA dose screening (198 participants), and 27 Phase IIB dose finding (1879 participants). All studies adopted a unidimensional approach. Time was the most frequent dimension investigated (53%), followed by intensity (29%), and scheduling (18%). Overall, 95% studies reported an efficacy outcome; however, only 65% reported dose and 45% reported safety. Across studies, 61% were at high risk of bias, and the average percentage reporting of intervention description and quality was 61% and 67%, respectively.

CONCLUSION

This review highlights a need to undertake more high-quality, early-phase studies that systematically articulate intervention doses from a multidimensional perspective in the field of behavioral motor stroke recovery. To address this gap, we need to invest in adapting early phase trial designs, especially Phase I, to support multidimensional dose articulation.

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.

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).

How Effective Are Interventions to Increase Physical Activity Levels among Older Inpatients Receiving Rehabilitation, without Increasing the Amount of Therapy? A Systematic Review

Purpose: We systematically reviewed the effectiveness of interventions to increase physical activity in older adults (aged ≥ 60 y), admitted for inpatient rehabilitation, without increasing the amount of therapy. Method: Five electronic databases were systematically searched to identify English-language articles reporting controlled trials of interventions to increase the physical activity (through participation or behavioural change) of older adults receiving inpatient rehabilitation. Trials were excluded if an intervention increased the intensity of usual care, either during the week or on the weekend. Two reviewers independently completed trial selection, quality assessment, and data extraction. Data were synthesized descriptively, and effect sizes with 95% CIs were calculated. Results: Of the 316 articles identified, 3 were included. Two were activity-based, and 1 was a behavioural change intervention. Physical activity was significantly improved in the behavioural change intervention trial that occurred during therapy (d = 0.27; 95% CI: 0.02, 0.52) and non-therapy time (d = 0.43; 95% CI: 0.19, 0.68). Participants in all trials were sedentary for the vast majority of the day. Conclusions: Older adults in inpatient rehabilitation have a high level of inactivity. Evidence is lacking that interventions increase physical activity in older adults admitted to inpatient rehabilitation without increasing the amount of time in therapy. Evidence from one trial indicates that behaviour-based strategies are effective for increasing physical activity levels in the inpatient rehabilitation setting.

How Much Allied Health Therapy Care Is Enough? An Evidence Scan

Purpose: Pressure to eliminate low-value health care is increasing internationally. This pressure has produced an urgent need to identify evidence-based methods to determine the value of allied health (AH) care, particularly to recognize when additional AH care adds no further benefits. This article reports on the published methods of determining the value of AH care. Method: We systematically scanned PubMed, MEDLINE, AMED, CINAHL, PsycINFO, and the Grey Literature Review database from inception until July 2018 for peer-reviewed English-language literature. Hierarchy of evidence and information on study design and the methods or measures used to determine the value of AH care were extracted. Results: Of 189 articles, 30 were potentially relevant; after the full text was read, all were included. Of these, 24 reported on ways of determining the value of AH care, and 6 described the optimal provision of AH episodes of care. No methods were reported that could be applied to establish when enough AH therapy had been provided. Conclusion: This review found a variety of attributes of value in AH care, but no standard value measure or methods to determine what constituted enough AH care. Repeated measurement of the standard attributes of value and costs is required throughout episodes of AH care to better understand the impact of AH care from the different stakeholders' perspectives.

Mapping the Functional Independence Measure to a multi-attribute utility instrument for economic evaluations in rehabilitation: a secondary analysis of randomized controlled trial data

Purpose: To test whether the Functional Independence Measure (FIM) could be mapped to the EQ-5D-3L to give researchers a viable but "second-best" option for calculating quality-adjusted life-years (QALYs) and conducting a cost-utility analysis when only clinical outcomes have been collected.Materials and methods: Secondary analysis of repeated measures data collected during a randomized controlled trial (n = 3506 observations) at two inpatient rehabilitation centres. Participants had a mean age of 74 (SD 13) years, 63% were women and 58% were admitted with an orthopaedic diagnosis. Ordinary least-squares regression and adjusted limited dependent variable mixture models were used to estimate regression-based mappings. Performance was evaluated based on mean absolute error and the proportion of errors in excess of the minimally important difference.Results: In orthopaedic and neurological patients, high mean absolute errors (0.2 on the quality-adjusted life years scale) and a high proportion of errors (60%) in excess of the minimally important difference suggest that predicted EQ-5D-3L values provided a poor substitute for observed EQ-5D-3L values.Conclusions: Regression-based mappings from the FIM to the EQ-5D-3L are error-prone and unsuitable for calculating QALYs in rehabilitation patients. Researchers and rehabilitation professionals should therefore include a multi-attribute utility instrument such as the EQ-5D as well as the FIM to evaluate the effect of rehabilitation interventions and in rehabilitation registries. This will provide additional information on health-related quality of life and support cost-utility analyses.Implications for rehabilitationThe Functional Independence Measure (FIM) cannot be used to calculate quality-adjusted life-years (QALYs) for cost-utility analyses.Predicting QALYs from FIM data is a poor substitute for direct measurement of QALYs in orthopaedic or neurological rehabilitation populations.Multi-attribute utility instruments (MAUIs) allow direct measurement of QALYs, as well as providing a patient-reported measure of clinical quality and outcomes in rehabilitation.A MAUI should be included routinely in clinical practice by rehabilitation professionals as well as in rehabilitation trials and registries to track patient outcomes and improve clinical practice.

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.

Non-pharmacological interventions for the improvement of post-stroke activities of daily living and disability amongst older stroke survivors: A systematic review

Globally, stroke remains a leading cause of death and disability, with older adults disproportionately affected. Numerous non-pharmacological stroke rehabilitation approaches are in use to address impairments, but their efficacy in older persons is largely unknown. This systematic review examined the evidence for such interventions as part of the Optimal Evidence-Based Non-Drug Therapies in Older Persons (ONTOP) project conducted under an European Union funded project called the Software Engine for the Assessment and Optimisation of Drug and Non-Drug Therapies in Older Persons (SENATOR) [http://www.senator-project.eu]. A Delphi panel of European geriatric experts agreed activities of daily living and disability to be of critical importance as stroke rehabilitation outcomes. A comprehensive search strategy was developed and five databases (Pubmed, CINAHL, Embase, PsycInfo and Cochrane Database of Systematic Reviews) searched for eligible systematic reviews. Primary studies meeting our criteria (non-pharmacologic interventions, involving stroke survivors aged ≥65 years, assessing activities of daily living and/or disability as outcome) were then identified from these reviews. Eligible papers were double reviewed, and due to heterogeneity, narrative analysis performed. Cochrane risk of bias and GRADE assessment tools were used to assess bias and quality of evidence, allowing us to make recommendations regarding specific non-pharmacologic rehabilitation in older stroke survivors. In total, 72 primary articles were reviewed spanning 14 types of non-pharmacological intervention. Non-pharmacological interventions based on physiotherapy and occupational therapy techniques improved activities of daily living amongst older stroke survivors. However, no evidence was found to support use of any non-pharmacological approach to benefit older stroke survivors' disability. Evidence was limited by poor study quality and the small number of studies targeting older stroke survivors. We recommend future studies explore such interventions exclusively in older adult populations and improve methodological and outcome reporting.

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].

Effects of a 6-month self-rehabilitation programme in addition to botulinum toxin injections and conventional physiotherapy on limitations of patients with spastic hemiparesis following stroke (ADJU-TOX): protocol study for a randomised controlled, investigator blinded study

INTRODUCTION

Home-based self-rehabilitation programmes combined with botulinum toxin injections (BTIs) appear to be a relevant approach to increase the recommended intensive rehabilitation of patients with spasticity following a stroke. The literature highlights a lack of evidence of beneficial effects of this adjuvant therapy to reduce limitations of patients with stroke. The aim of this study is to assess the effects of a 6-month self-rehabilitation programme in adjunction to BTI, in comparison with BTI alone, to reduce limitations of patients with spasticity following a stroke.

METHODS AND ANALYSIS

220 chronic patients will participate to this multicentre, prospective, randomised, controlled, assessor blinded study. All patients will benefit from two successive BTI (3 months apart), and patients randomised in the self-rehabilitation group will perform in adjunction 6 months of self-rehabilitation at home. All patients continue their conventional physiotherapy. The main outcome is the primary treatment goal (PTG), which will be determined jointly by the patient and the medical doctor using Goal Attainment Scaling. Impairments and functions, quality of life, mood and fatigue will be assessed. Botulinum toxin will be injected into the relevant muscles according to the PTG. Patients in the self-rehab group will be taught the self-rehabilitation programme involving respectively 10 min of stretching, 10 min of strengthening and 10 min of task-oriented exercises, corresponding to their PTG. Compliance to the self-rehabilitation programme will be monitored.

ETHICS AND DISSEMINATION

Patients will sign written informed consent. Ethical approval was obtained from ethics committee. The results will be disseminated in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients.

TRIAL REGISTRATION NUMBER

NCT02944929.

Extra practice outside therapy sessions to maximize training opportunity during inpatient rehabilitation after traumatic brain injury

OBJECTIVE

To determine if extra practice outside therapy sessions can be conducted for patients with traumatic brain injury and identify factors that influence their participation.

METHODS

A purpose-designed survey was conducted on consecutive eligible patients with traumatic brain injury and their relatives on discharge from inpatient rehabilitation.

RESULTS

In total, 68 of the 69 of patients who took part in the survey reported that they participated in extra practice outside therapy sessions. Also, 58% reported that they conducted extra practice more than three times a week on average and 70% reported no barriers in conducting extra practice. Patients with poor motivation, reduced executive functioning and less severe brain injury are less likely to participate in extra practice and may require more support. Relatives tended to be involved in extra practice for patients who were dependent. A wide range of barriers were identified with poor motivation and lack of confidence being the main ones.

CONCLUSION

With appropriate support, extra practice outside therapy sessions is generally feasible to maximize training opportunity for patients with traumatic brain injury. Motivation, perception of being listened to, executive functioning and severity of injury are factors that influence participation in extra practice. Strategies that improve motivation, interaction and confidence are likely to enhance participation. Relatives are a useful source of support for the more dependent patients.

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.

Factors Influencing the Overall Satisfaction in Patients With Severe Brain Injury With Physiotherapy Services During Inpatient Rehabilitation

OBJECTIVE

To determine what influences the satisfaction of rehabilitation inpatients and their relatives with physiotherapy after severe traumatic brain injury.

DESIGN

A prospective purpose-designed survey of consecutive eligible patients discharged from a metropolitan brain injury unit.

PARTICIPANTS

A total of 65 patients with severe traumatic brain injury and 32 relatives.

RESULTS

The vast majority of patients (99%) and relatives (97%) reported being "satisfied" or "highly satisfied" with the service. Patients' overall satisfaction was influenced by the extent of actual and perceived improvement, satisfaction with certain aspects of service delivery, and quality of interaction with physiotherapy staff. Satisfaction with the amount of therapy was the key determinant for patients' overall satisfaction, whereas relatives' overall satisfaction was influenced primarily by how well they felt they were listened to by physiotherapy staff.

CONCLUSION

The high satisfaction of the patients and relatives suggests that our brain injury unit provides physiotherapy that meets their expectations. Promoting recovery, providing high-quality care, and ensuring good interaction are ways to maintain high satisfaction of patients and relatives with the service. In addition, staff may have to pay particular attention to patients' satisfaction with the amount of therapy and ensure that relatives' needs are listened to.

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].

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.

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.

The effect of altering a single component of a rehabilitation programme on the functional recovery of stroke patients: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of altering a single component of a rehabilitation programme (e.g. adding bilateral practice alone) on functional recovery after stroke, defined using a measure of activity.

DATA SOURCES

A search was conducted of Medline/Pubmed, CINAHL and Web of Science.

REVIEW METHODS

Two reviewers independently assessed eligibility. Randomized controlled trials were included if all participants received the same base intervention, and the experimental group experienced alteration of a single component of the training programme. This could be manipulation of an intrinsic component of training (e.g. intensity) or the addition of a discretionary component (e.g. augmented feedback). One reviewer extracted the data and another independently checked a subsample (20%). Quality was appraised according to the PEDro scale.

RESULTS

Thirty-six studies (n = 1724 participants) were included. These evaluated nine training components: mechanical degrees of freedom, intensity of practice, load, practice schedule, augmented feedback, bilateral movements, constraint of the unimpaired limb, mental practice and mirrored-visual feedback. Manipulation of the mechanical degrees of freedom of the trunk during reaching and the addition of mental practice during upper limb training were the only single components found to independently enhance recovery of function after stroke.

CONCLUSION

This review provides limited evidence to support the supposition that altering a single component of a rehabilitation programme realises greater functional recovery for stroke survivors. Further investigations are required to determine the most effective single components of rehabilitation programmes, and the combinations that may enhance functional recovery.

Rehabilitation after stroke in older people

Stroke is a leading cause of disability and therefore rehabilitation is a major part of patient care. Most interventions do not target aged patient but there is unequivocal evidence to promote rehabilitation in multidisciplinary stroke units or integrated care of a multidisciplinary team in the community. Most research has focused on the effect of interventions on recovery in different forms of impairment and disability. The most promising options for motor recovery of the arm include constraint-induced movement therapy and robotic-assisted strategies. Interventions to improve postural stability and gait include fitness training, high-intensity therapy, and repetitive-task training. However, information about the clinical effect of various strategies of cognitive rehabilitation and strategies for aphasia and dysarthria is scarce. Several large trials of rehabilitation practice are underway to test these interventions in the elderly, either alone or in combination with early mobilisation, cardiorespiratory fitness training and physical exercise.

Circuit Class or Seven-Day Therapy for Increasing Intensity of Rehabilitation after Stroke: Protocol of the CIRCIT Trial

Rationale

There is strong evidence for a dose–response relationship between physical therapy early after stroke and recovery of function. The optimal method of maximizing physical therapy within finite health care resources is unknown.

Aims

To determine the effectiveness and cost-effectiveness of two alternative models of physical therapy service delivery (seven-days per week therapy services or group circuit class therapy over five-days a week) to usual care for people receiving inpatient rehabilitation after stroke.

Design

Multicenter, three-armed randomized controlled trial with blinded assessment of outcomes.

Study

A total of 282 people admitted to inpatient rehabilitation facilities after stroke with an admission functional independence measure (FIM) score within the moderate range (total 40–80 points or motor 38–62 points) will be randomized to receive one of three interventions: • usual care therapy over five-days a week • standard care therapy over seven-days a week, or • group circuit class therapy over five-days a week. Participants will receive the allocated intervention for the length of their hospital stay. Analysis will be by intention-to-treat.

Outcomes

The primary outcome measure is walking ability (six-minute walk test) at four-week postintervention with three- and six-month follow-up. Economic analysis will include a costing analysis based on length of hospital stay and staffing/resource costs and a cost-utility analysis (incremental quality of life per incremental cost, relative to usual care). Secondary outcomes include walking speed and independence, ability to perform activities of daily living, arm function, quality of life and participant satisfaction.

Effects of Augmented Exercise Therapy on Outcome of Gait and Gait-Related Activities in the First 6 Months After Stroke

Background and Purpose—

The purpose of this study was to determine the effects of augmented exercise therapy on gait, gait-related activities, and (basic and extended) activities of daily living within the first 6 months poststroke.

Methods—

A systematic literature search in electronic databases from 1990 until October 2010 was performed. Randomized controlled trials were included in which the experimental group spent augmented time in lower-limb exercise therapy compared with the control group. Outcomes were gait, gait-related activities, and (extended) activities of daily living. Results from individual studies were pooled by calculating the summary effect sizes. Subgroup analyses were applied for a treatment contrast of ≥16 hours, timing poststroke, type of control intervention, and methodological quality.

Results—

Fourteen (N=725) of 4966 identified studies were included. Pooling resulted in small to moderate significant summary effect sizes in favor of augmented exercise therapy for walking ability, comfortable and maximum walking speed, and extended activities of daily living. No significant effects were found for basic activities of daily living. Subgroup analysis did not show a significant effect modification.

Conclusions—

Dose–response trials in stroke rehabilitation are heterogeneous. The present meta-analysis suggests that increased time spent on exercise of gait and gait-related activities in the first 6 months poststroke results in significant small to moderate effects in terms of walking ability, walking speed, and extended activities of daily living. High-quality dose–response exercise therapy trials are needed with identical treatment goals but incremental levels of intensity.

Extra physical therapy reduces patient length of stay and improves functional outcomes and quality of life in people with acute or subacute conditions: a systematic review

OBJECTIVES

To investigate whether extra physical therapy intervention reduces length of stay and improves patient outcomes in people with acute or subacute conditions.

DATA SOURCES

Electronic databases CINAHL, MEDLINE, AMED, PEDro, PubMed, and EMBASE were searched from the earliest date possible through May 2010. Additional trials were identified by scanning reference lists and citation tracking.

STUDY SELECTION

Randomized controlled trials evaluating the effect of extra physical therapy on patient outcomes were included for review. Two reviewers independently applied the inclusion and exclusion criteria, and any disagreements were discussed until consensus could be reached. Searching identified 2826 potentially relevant articles, of which 16 randomized controlled trials with 1699 participants met inclusion criteria.

DATA EXTRACTION

Data were extracted using a predefined data extraction form by 1 reviewer and checked for accuracy by another. Methodological quality of trials was assessed independently by 2 reviewers using the PEDro scale.

DATA SYNTHESIS

Pooled analyses with random effects model to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs) were used in meta-analyses. When compared with standard physical therapy, extra physical therapy reduced length of stay (SMD=-.22; 95% CI, -.39 to -.05) (mean difference of 1d [95% CI, 0-1] in acute settings and mean difference of 4d [95% CI, 0-7] in rehabilitation settings) and improved mobility (SMD=.37; 95% CI, .05-.69), activity (SMD=.22; 95% CI, .07-.37), and quality of life (SMD=.48; 95% CI, .29-.68). There were no significant changes in self-care (SMD=.35; 95% CI, -.06-.77).

CONCLUSIONS

Extra physical therapy decreases length of stay and significantly improves mobility, activity, and quality of life. Future research could address the possible benefits of providing extra services from other allied health disciplines in addition to physical therapy.

Effectiveness of automated locomotor training in patients with acute incomplete spinal cord injury: a randomized controlled multicenter trial

Background

A large proportion of patients with spinal cord injury (SCI) regain ambulatory function. However, during the first 3 months most of the patients are not able to walk unsupported. To enable ambulatory training at such an early stage the body weight is partially relieved and the leg movements are assisted by two therapists. A more recent approach is the application of robotic based assistance which allows for longer training duration. From motor learning science and studies including patients with stroke, it is known that training effects depend on the duration of the training. Longer trainings result in a better walking function. The aim of the present study is to evaluate if prolonged robot assisted walking training leads to a better walking outcome in patients with incomplete SCI and whether such training is feasible or has undesirable effects.

Methods/Design

Patients from multiple sites with a subacute incomplete SCI and who are not able to walk independently will be randomized to either standard training (3-5 sessions per week, session duration maximum 25 minutes) or an intensive training (3-5 sessions per week, session duration minimum 50 minutes). After 8 weeks of training and 4 months later the walking ability, the occurrence of adverse events and the perceived rate of exertion as well as the patients' impression of change will be compared between groups.

Trial registration

This study is registered at clinicaltrials.gov, identifier: NCT01147185.

Dose–Response Study of Mobilisation and Tactile Stimulation Therapy for the Upper Extremity Early After Stroke

Background. Physical therapy doses may need to be higher than provided in current clinical practice, especially for patients with severe paresis. The authors aimed to find the most effective and feasible dose of Mobilisation and Tactile Stimulation (MTS), which includes joint and soft-tissue mobilization and passive or active-assisted movement to enhance voluntary muscle contraction. Methods. This 2-center, randomized, controlled, observer-blinded feasibility trial compared conventional rehabilitation but no extra therapy (group 1) with conventional therapy plus 1 of 3 daily doses of MTS, up to 30 (group 2), 60 (group 3), or 120 (group 4) minutes for 14 days. The 76 participants had substantial paresis (Motricity Index [MI] < 61) a mean of 30 days (standard deviation [SD] = 20 days) after anterior circulation stroke. MTS was delivered using a standardized schedule of techniques (eg, sensory input, active-assisted movement). The primary outcome was the Motricity Index (MI) and secondary outcome was the Action Research Arm Test (ARAT) tested on day 16. Adverse events were monitored daily. Results. No difference was found in the change in control group MI compared with each of the 3 intervention groups ( P = .593) or in the ARAT. Mean actual daily treatment time for all MTS groups was less than expected. The attrition rate was 1.3%. No adverse events related to overuse occurred. Conclusion. The authors were not able to deliver a maximum dose of 120 minutes of daily therapy each day. The mean daily dose of MTS feasible for subsequent evaluation is between 37 and 66 minutes.

The effects of increased dose of exercise-based therapies to enhance motor recovery after stroke: a systematic review and meta-analysis

BACKGROUND

Exercise-based therapy is known to enhance motor recovery after stroke but the most appropriate amount, i.e. the dose, of therapy is unknown. To determine the strength of current evidence for provision of a higher dose of the same types of exercise-based therapy to enhance motor recovery after stroke.

METHODS

An electronic search of: MEDLINE, EMBASE, CINHAL, AMED, and CENTRAL was undertaken. Two independent reviewers selected studies using predetermined inclusion criteria: randomised or quasi randomised controlled trials with or without blinding of assessors; adults, 18+ years, with a clinical diagnosis of stroke; experimental and control group interventions identical except for dose; exercise-based interventions investigated; and outcome measures of motor impairment, movement control or functional activity. Two reviewers independently extracted outcome and follow-up data. Effect sizes and 95% confidence intervals were interpreted with reference to risk of bias in included studies.

RESULTS

9 papers reporting 7 studies were included. Only 3 of the 7 included studies had all design elements assessed as low risk of bias. Intensity of the control intervention ranged from a mean of 9 to 28 hours over a maximum of 20 weeks. Experimental groups received between 14 and 92 hours of therapy over a maximum of 20 weeks. The included studies were heterogeneous with respect to types of therapy, outcome measures and time-points for outcome and follow-up. Consequently, most effect sizes relate to one study only. Single study effect sizes suggest a trend for better recovery with increased dose at the end of therapy but this trend was less evident at follow-up Meta-analysis was possible at outcome for: hand-grip strength, -10.1 [-19.1,-1.2] (2 studies, 97 participants); Action Research Arm Test (ARAT), 0.1 [-5.7,6.0] (3 studies, 126 participants); and comfortable walking speed, 0.3 [0.1,0.5] (2 studies, 58 participants). At follow-up, between 12 and 26 weeks after start of therapy, meta-analysis findings were: Motricity Arm, 10.7 [1.7,19.8] (2 studies, 83 participants); ARAT, 2.2 [-6.0,10.4] (2 studies, 83 participants); Rivermead Mobility, 1.0 [-0.6, 2.5] (2 studies, 83 participants); and comfortable walking speed, 0.2 [0.0,0.4] (2 studies, 60 participants).

CONCLUSIONS

Current evidence provides some, but limited, support for the hypothesis that a higher dose of the same type of exercised-based therapy enhances motor recovery after stroke. Prospective dose-finding studies are required.

Recovery after stroke: a 1-year profile

PURPOSE

To document the course of recovery in a group of first stroke patients, with stroke of moderate severity, over a 1-year period. Evaluation of recovery is important for estimating rehabilitation needs.

METHOD

One-year observational study of 23 acute first stroke patients. Recovery was assessed at 15 specific intervals using measures of impairment, activity, social participation and quality of life.

RESULTS

There were significant changes in impairment (p < 0.05) and motor disability over 1 year (F ratio = 75.627, d.f. = 4, p < or = 0.0001) including the period between 6 and 12 months though recovery did appear to slow down after a 9-week 'turning point'. Significant improvements in social participation were also seen between 6 and 12 months (p = 0.0021). Quality of life did not change and patients' quality of life scores indicated levels of 'severe distress' at 6 (57.8 [8.8]) and 12 months (58.9 [8.6]).

CONCLUSIONS

Recovery after stroke was detectable beyond 6 months using detailed measures. This demonstration of late recovery has therapeutic implications. An increased understanding of the course of recovery following stroke could provide a basis for evaluating the varied aspects of therapeutic intervention in stroke rehabilitation.

Motor recovery after stroke: a systematic review

Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. In this Review, we aimed to provide an overview of the available evidence on interventions for motor recovery after stroke through the evaluation of systematic reviews, supplemented by recent randomised controlled trials. Most trials were small and had some design limitations. Improvements in recovery of arm function were seen for constraint-induced movement therapy, electromyographic biofeedback, mental practice with motor imagery, and robotics. Improvements in transfer ability or balance were seen with repetitive task training, biofeedback, and training with a moving platform. Physical fitness training, high-intensity therapy (usually physiotherapy), and repetitive task training improved walking speed. Although the existing evidence is limited by poor trial designs, some treatments do show promise for improving motor recovery, particularly those that have focused on high-intensity and repetitive task-specific practice.

Overground physical therapy gait training for chronic stroke patients with mobility deficits

BACKGROUND

Overground gait training forms a major part of physical therapy services for chronic stroke patients in almost every setting. Overground gait training refers to physical therapists' observation and cueing of the patient's walking pattern along with related exercises, but does not include high-technology aids such as functional electrical stimulation or body weight support.

OBJECTIVES

To assess the effects of overground physical therapy gait training on walking ability for chronic stroke patients with mobility deficits.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched March 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2008), MEDLINE (1966 to May 2008), EMBASE (1980 to May 2008), CINAHL (1982 to May 2008), AMED (1985 to March 2008), Science Citation Index Expanded (1981 to May 2008), ISI Proceedings (Web of Science, 1982 to May 2006), Physiotherapy Evidence Database (http://www.pedro.org.au/) (May 2008), REHABDATA (http://www.naric.com/research/rehab/) (1956 to May 2008), http://www.clinicaltrials.gov (May 2008), http://www.controlled-trials.com/ (May 2008), and http://www.strokecenter.org/ (May 2008). We also searched reference lists of relevant articles, and contacted authors and trial investigators.

SELECTION CRITERIA

Randomised controlled trials comparing overground physical therapy gait training with a placebo intervention or no treatment for chronic stroke patients with mobility deficits.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently selected trials. Three authors independently extracted data and assessed quality. We contacted study authors for additional information.

MAIN RESULTS

We included nine studies involving 499 participants. We found no evidence for a benefit on the primary variable, post-test gait function, based on three studies with 269 participants. Uni-dimensional performance variables did show significant effects post-test. Gait speed increased by 0.07 metres per second (95% confidence interval (CI) 0.05 to 0.10) based on seven studies with 396 participants, timed up-and-go (TUG) test improved by 1.81 seconds (95% CI -2.29 to -1.33), and six-minute-walk test (6MWT) increased by 26.06 metres (95% CI 7.14 to 44.97) based on four studies with 181 participants. We found no significant differences in deaths/disabilities or in adverse effects, based on published reports or personal communication from all of the included studies.

AUTHORS' CONCLUSIONS

We found insufficient evidence to determine if overground physical therapy gait training benefits gait function in patients with chronic stroke, though limited evidence suggests small benefits for uni-dimensional variables such as gait speed or 6MWT. These findings must be replicated by large, high quality studies using varied outcome measures.

The impact of increased duration of exercise therapy on functional recovery following stroke--what is the evidence?

This article focuses on the impact of increased duration of exercise therapy on functional recovery after stroke. A comprehensive literature search using multiple databases was used to identify all relevant randomized controlled trials. Their quality was reviewed by two independent assessors, and a narrative systematic review and meta-analysis was completed. Methodological quality of all the 20 randomized controlled trials (RCTs) identified had a median of 6 points (range 5-8) on the 10-point PEDro scale. A meta-analysis was completed for studies that had a common outcome measure. For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) were expressed as standardized mean differences (SMD). The results of the meta-analysis demonstrated that increased duration of exercise therapy time has a small but positive effect on activities of daily living as measured by the Barthel Index (SES 0.13; CI 0.01-0.25; Z = 2.15; p = .03) and that these improvements are maintained over a 6-month period (SES 0.15; CI 0.05-0.26; Z = 2.8; p = .00). Pooling reported differences in the various upper and lower extremity outcome measures demonstrated no significant SESs. However, the meta-analysis is supportive of the hypothesis that additional, focused exercise on the lower extremity has a favourable effect on lower extremity impairment and walking speed. The narrative review raises a number of issues that need to be considered in the development of future RCTs.

An exploratory randomized controlled trial of assisted practice for improving sit-to-stand in stroke patients in the hospital setting

Objectives: To evaluate the amount of practice achieved and assess potential for effects on performance of 30 minutes of daily training in sit-to-stand.

Design: Randomized controlled pilot study.

Setting: Stroke rehabilitation unit, UK.

Participants: Eighteen stroke patients needing `stand by' help to sit-to-stand.

Interventions: In addition to usual rehabilitation the experimental group (n = 9) practised sit-to-stand and leg strengthening exercises for 30 minutes, on weekdays for two weeks, with a physiotherapy assistant. The control group received arm therapy.

Main outcome measures: Frequency of sit-to-stands per day. Performance measures: rise time, weight taken through the affected foot at `thighs off', number of attempts needed to achieve three successful sit-to-stands and the number of sit-to-stands performed in 60 seconds. Outcome was measured one and two weeks after baseline assessment.

Results: Sit-to-stand frequency averaged 18 per day. Thirty minutes of practice in sit-to-stand resulted in a mean of 50 (SD 17.2) extra stands per day. There was a significant mean difference of 10% body weight taken through the affected foot after one week of intervention: The control group had reduced weight through the affected leg while the training group increased weight (F1,16 = 11.1, P= 0.004, 95% confidence interval (CI) -16.61 to -3.72). No significant differences between groups were found on other measures. Results two weeks after baseline were inconclusive due to loss of five participants.

Conclusions: Task-specific practice given for 30 minutes a day appears promising for patients learning to sit-to-stand.

Patient satisfaction with circuit class therapy and individual physiotherapy

The purpose of this observational study was to determine patients' levels of satisfaction with circuit class therapy and individual physiotherapy sessions on a stroke rehabilitation unit.

Forty-nine persons participated in both circuit class therapy and individual physiotherapy sessions as part of standard inpatient rehabilitation following stroke. A purpose-designed questionnaire was administered to investigate patient satisfaction.

High degrees of satisfaction were reported with both methods of physiotherapy service delivery. Individual sessions were perceived as being more tailored to participants' goals, whereas participants reported that circuit classes offered a more supportive environment than the individual therapy sessions. Participants were satisfied with the amount of supervision and assistance provided in both forms of physiotherapy service delivery. No distinct advantage was seen for one form of therapy over the other in terms of patient satisfaction.

Gait training strategies to optimize walking ability in people with stroke: a synthesis of the evidence

Stroke is a leading cause of long-term disability. Impairments resulting from stroke lead to persistent difficulties with walking and, subsequently, improved walking ability is one of the highest priorities for people living with a stroke. In addition, walking ability has important health implications in providing protective effects against secondary complications common after a stroke such as heart disease or osteoporosis. This paper systematically reviews common gait training strategies (neurodevelopmental techniques, muscle strengthening, treadmill training and intensive mobility exercises) to improve walking ability. The results (descriptive summaries as well as pooled effect sizes) from randomized controlled trials are presented and implications for optimal gait training strategies are discussed. Novel and emerging gait training strategies are highlighted and research directions proposed to enable the optimal recovery and maintenance of walking ability.

Effects of Exercise Training Programs on Walking Competency After Stroke

To determine the effectiveness of training programs that focus on lower-limb strengthening, cardiorespiratory fitness, or gait-oriented tasks in improving gait, gait-related activities, and health-related quality of life after stroke. Randomized controlled trials (RCTs) were searched for in the databases of Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, Physiotherapy Evidence Database (PEDro), EMBASE, Database of the Dutch Institute of Allied Health Care, and CINAHL. Databases were systematically searched by two independent researchers. The following inclusion criteria were applied: (1) participants were people with stroke, older than 18 yrs; (2) one of the outcomes focused on gait-related activities; (3) the studies evaluated the effectiveness of therapy programs focusing on lower-limb strengthening, cardiorespiratory fitness, or gait-oriented training; and (4) the study was published in English, German, or Dutch. Studies were collected up to November 2005, and their methodological quality was assessed using the PEDro scale. Studies were pooled and summarized effect sizes were calculated. Best-evidence synthesis was applied if pooling was impossible. Twenty-one RCTs were included, of which five focused on lower-limb strengthening, two on cardiorespiratory fitness training (e.g., cycling exercises), and 14 on gait-oriented training. Median PEDro score was 7. Meta-analysis showed a significant medium effect of gait-oriented training interventions on both gait speed and walking distance, whereas a small, nonsignificant effect size was found on balance. Cardiorespiratory fitness programs had a nonsignificant medium effect size on gait speed. No significant effects were found for programs targeting lower-limb strengthening. In the best-evidence synthesis, strong evidence was found to support cardiorespiratory training for stair-climbing performance. Although functional mobility was positively affected, no evidence was found that activities of daily living, instrumental activities of daily living, or health-related quality of life were significantly affected by gait-oriented training. This review shows that gait-oriented training is effective in improving walking competency after stroke.

Establishing an effective quantity of physiotherapy after stroke: A discussion

Physiotherapy is a well-established part of stroke rehabilitation and the UK National Clinical Guidelines for Stroke recommend that patients should have as much therapy as is appropriate to their needs. However there is no conclusive evidence of a definitive amount of treatment that is effective.

This discussion paper seeks to explore four trends that appear to be emerging from current research on intensity of physiotherapy treatment, namely quantity of treatment, type of interventions used, influence of levels of impairment and lastly, responsiveness of different body parts for recovery.

The authors suggest that further research is needed to investigate some key issues. First of all, research should investigate whether the amount of traditional physiotherapy alone should be increased or if additional treatment should be focused on functional tasks and repetition, as advocated within neuroplasticity literature. Further investigation could also explore whether more intensive treatment is beneficial to all patients or only those with specific types of impairment and activity limitation. To reflect this concept, the possibility of establishing more careful matching of patients to treatments should be explored. Finally, it should be determined whether particular contributions to recovery, e.g. lower limb function, are more responsive to intensive treatment than others, e.g hand function.

Clinical practice. Rehabilitation after stroke

A 66-year-old man was suddenly unable to speak, follow directions, or move his right arm and leg. He received tissue plasminogen activator within 90 minutes. Four days later, his speech was limited to effortful answers of yes or no. He could not walk or use his right arm, and self-care tasks required maximal assistance. What advice would you offer him and his family regarding rehabilitation for his disabilities?

The impact of physical therapy on functional outcomes after stroke: what's the evidence?

OBJECTIVE

To determine the evidence for physical therapy interventions aimed at improving functional outcome after stroke.

METHODS

MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, PEDro, EMBASE and DocOnline were searched for controlled studies. Physical therapy was divided into 10 intervention categories, which were analysed separately. If statistical pooling (weighted summary effect sizes) was not possible due to lack of comparability between interventions, patient characteristics and measures of outcome, a best-research synthesis was performed. This best-research synthesis was based on methodological quality (PEDro score).

RESULTS

In total, 151 studies were included in this systematic review; 123 were randomized controlled trials (RCTs) and 28 controlled clinical trials (CCTs). Methodological quality of all RCTs had a median of 5 points on the 10-point PEDro scale (range 2-8 points). Based on high-quality RCTs strong evidence was found in favour of task-oriented exercise training to restore balance and gait, and for strengthening the lower paretic limb. Summary effect sizes (SES) for functional outcomes ranged from 0.13 (95% Cl 0.03-0.23) for effects of high intensity of exercise training to 0.92 (95% Cl 0.54-1.29) for improving symmetry when moving from sitting to standing. Strong evidence was also found for therapies that were focused on functional training of the upper limb such as constraint-induced movement therapy (SES 0.46; 95% Cl 0.07-0.91), treadmill training with or without body weight support, respectively 0.70 (95% Cl 0.29-1.10) and 1.09 (95% Cl 0.56-1.61), aerobics (SES 0.39; 95% Cl 0.05-0.74), external auditory rhythms during gait (SES 0.91; 95% Cl 0.40-1.42) and neuromuscular stimulation for glenohumeral subluxation (SES 1.41; 95% Cl 0.76-2.06). No or insufficient evidence in terms of functional outcome was found for: traditional neurological treatment approaches; exercises for the upper limb; biofeedback; functional and neuromuscular electrical stimulation aimed at improving dexterity or gait performance; orthotics and assistive devices; and physical therapy interventions for reducing hemiplegic shoulder pain and hand oedema.

CONCLUSIONS

This review showed small to large effect sizes for task-oriented exercise training, in particular when applied intensively and early after stroke onset. In almost all high-quality RCTs, effects were mainly restricted to tasks directly trained in the exercise programme.

Effects of augmented exercise therapy time after stroke: a meta-analysis

BACKGROUND AND PURPOSE

To present a systematic review of studies that addresses the effects of intensity of augmented exercise therapy time (AETT) on activities of daily living (ADL), walking, and dexterity in patients with stroke.

SUMMARY OF REVIEW

A database of articles published from 1966 to November 2003 was compiled from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE, and PiCarta using combinations of the following key words: stroke, cerebrovascular disorders, physical therapy, physiotherapy, occupational therapy, exercise therapy, rehabilitation, intensity, dose-response relationship, effectiveness, and randomized controlled trial. References presented in relevant publications were examined as well as abstracts in proceedings. Studies that satisfied the following selection criteria were included: (1) patients had a diagnosis of stroke; (2) effects of intensity of exercise training were investigated; and (3) design of the study was a randomized controlled trial (RCT). For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) expressed in standard deviation units (SDU) were calculated for ADL, walking speed, and dexterity using fixed and random effect models. Correlation coefficients were calculated between observed individual effect sizes on ADL of each study, additional time spent on exercise training, and methodological quality. Cumulative meta-analyses (random effects model) adjusted for the difference in treatment intensity in each study was used for the trials evaluating the effects of AETT provided. Twenty of the 31 candidate studies, involving 2686 stroke patients, were included in the synthesis. The methodological quality ranged from 2 to 10 out of the maximum score of 14 points. The meta-analysis resulted in a small but statistically significant SES with regard to ADL measured at the end of the intervention phase. Further analysis showed a significant homogeneous SES for 17 studies that investigated effects of increased exercise intensity within the first 6 months after stroke. No significant SES was observed for the 3 studies conducted in the chronic phase. Cumulative meta-analysis strongly suggests that at least a 16-hour difference in treatment time between experimental and control groups provided in the first 6 months after stroke is needed to obtain significant differences in ADL. A significant SES supporting a higher intensity was also observed for instrumental ADL and walking speed, whereas no significant SES was found for dexterity.

CONCLUSIONS

The results of the present research synthesis support the hypothesis that augmented exercise therapy has a small but favorable effect on ADL, particularly if therapy input is augmented at least 16 hours within the first 6 months after stroke. This meta-analysis also suggests that clinically relevant treatment effects may be achieved on instrumental ADL and gait speed.