Limited evidence of physical therapy on balance after stroke: A systematic review and meta-analysis

The effect of balance training using touch controller-based fully immersive virtual reality devices on balance and walking ability in patients with stroke: A pilot randomized controlled trial

BACKGROUND

Fully immersive virtual reality (FIVR) removes information from the real world and replaces it with computer-generated data, creating the impression of being in a genuine virtual world.

OBJECTIVE

To evaluate the effects of balance training using touch controller-based FIVR devices on balance and walking abilities in patients with stroke.

METHODS

The participants were randomly categorized into the FIVR group (n = 18) and control group (n = 18). The control group received conventional therapy for 5 sessions, 30 minutes per week, for 5 weeks. The FIVR group practiced additional touch controller-based FIVR balance training for 3 sessions of 30 minutes per week for 5 weeks and changes in balance and walking ability were measured for both groups.

RESULTS

Touch controller-based FIVR balance training significantly improved the Berg Balance Scale (BBS) and, timed up-and-go (TUG) test results (P < .01). There was also significant improvement in gait abilities, including gait velocity, step length of the affected side, stride length, and single limb support of the affected side (P < .01).

CONCLUSION

Touch controller-based FIVR balance training improved balance and gait in patients with stroke. These results indicate that touch controller-based FIVR balance training is feasible and suitable for patients with stroke, providing a promising avenue for rehabilitation.

Exoskeleton rehabilitation robot training for balance and lower limb function in sub-acute stroke patients: a pilot, randomized controlled trial

PURPOSE

This pilot study aimed to investigate the effects of REX exoskeleton rehabilitation robot training on the balance and lower limb function in patients with sub-acute stroke.

METHODS

This was a pilot, single-blind, randomized controlled trial. Twenty-four patients with sub-acute stroke (with the course of disease ranging from 3 weeks to 3 months) were randomized into two groups, including a robot group and a control group. Patients in control group received upright bed rehabilitation (n = 12) and those in robot group received exoskeleton rehabilitation robot training (n = 12). The frequency of training in both groups was once a day (60 min each) for 5 days a week for a total of 4 weeks. Besides, the two groups were evaluated before, 2 weeks after and 4 weeks after the intervention, respectively. The primary assessment index was the Berg Balance Scale (BBS), whereas the secondary assessment indexes included the Fugl-Meyer Lower Extremity Motor Function Scale (FMA-LE), the Posture Assessment Scale for Stroke Patients (PASS), the Activities of Daily Living Scale (Modified Barthel Index, MBI), the Tecnobody Balance Tester, and lower extremity muscle surface electromyography (sEMG).

RESULTS

The robot group showed significant improvements (P < 0.05) in the primary efficacy index BBS, as well as the secondary efficacy indexes PASS, FMA-LE, MBI, Tecnobody Balance Tester, and sEMG of the lower limb muscles. Besides, there were a significant differences in BBS, PASS, static eye-opening area or dynamic stability limit evaluation indexes between the robotic and control groups (P < 0.05).

CONCLUSIONS

This is the first study to investigate the effectiveness of the REX exoskeleton rehabilitation robot in the rehabilitation of patients with stroke. According to our results, the REX exoskeleton rehabilitation robot demonstrated superior potential efficacy in promoting the early recovery of balance and motor functions in patients with sub-acute stroke. Future large-scale randomized controlled studies and follow-up assessments are needed to validate the current findings.

CLINICAL TRIALS REGISTRATION

URL: https://www.chictr.org.cn/index.html.Unique identifier: ChiCTR2300068398.

Feature analysis of joint motion in paralyzed and non-paralyzed upper limbs while reaching the occiput: A cross-sectional study in patients with mild hemiplegia

The reaching motion to the back of the head with the hand is an important movement for daily living. The scores of upper limb function tests used in clinical practice alone are difficult to use as a reference when planning exercises for movement improvements. This cross-sectional study aimed to clarify in patients with mild hemiplegia the kinematic characteristics of paralyzed and non-paralyzed upper limbs reaching the occiput. Ten patients with post-stroke hemiplegia who attended the Department of Rehabilitation Medicine of the Jikei University Hospital and met the eligibility criteria were included. Reaching motion to the back of the head by the participants' paralyzed and non-paralyzed upper limbs was measured using three-dimensional motion analysis, and the motor time, joint angles, and angular velocities were calculated. Repeated measures multivariate analysis of covariance was performed on these data. After confirming the fit to the binomial logistic regression model, the cutoff values were calculated using receiver operating characteristic curves. Pattern identification using random forest clustering was performed to analyze the pattern of motor time and joint angles. The cutoff values for the movement until the hand reached the back of the head were 1.6 s for the motor time, 55° for the maximum shoulder joint flexion angle, and 145° for the maximum elbow joint flexion angle. The cutoff values for the movement from the back of the head to the hand being returned to its original position were 1.6 s for the motor time, 145° for the maximum elbow joint flexion angle, 53°/s for the maximum angular velocity of shoulder joint abduction, and 62°/s for the maximum angular velocity of elbow joint flexion. The numbers of clusters were three, four, and four for the outward non-paralyzed side, outward and return paralyzed side, and return non-paralyzed side, respectively. The findings obtained by this study can be used for practice planning in patients with mild hemiplegia who aim to improve the reaching motion to the occiput.

The effects of rhythmic auditory stimulation on functional ambulation after stroke: a systematic review

BACKGROUND

Several studies have reported the effect of rhythmic auditory stimulation (RAS) on functional ambulation in stroke patients, yet no systematic overview has yet been published. This study aims to synthesize the available evidence describing changes in stroke patients after RAS intervention for functional ambulation and the use of walking assistive devices, and to find out if the effect of RAS and music-based RAS differs depending on the lesioned area.

METHODS

The PubMed, PEDro, Cochrane Central Register of Controlled Trials, Web of Science, Scopus and CINAHL electronic databases were searched for reports evaluating the effect of RAS on walking in stroke patients, applying the PICOS criteria for the inclusion of studies.

RESULTS

Twenty one articles were included (948 stroke survivors). Most studies were of good methodological quality according to the PEDro scale, but they had a high risk of bias. The most consistent finding was that RAS improves walking and balance parameters in stroke patients in all phases compared to baseline and versus control groups with conventional treatment. Functional ambulation and the use of walking assistive devices were inconsistently reported. Several studies also suggest that RAS may be as good as other complementary therapies (horse-riding and visual cueing).

CONCLUSIONS

Despite the beneficial effects of RAS, the question remains as to whether it is better than other complementary therapies. Given the heterogeneity of the interventions, the interventions in control groups, the varied durations, and the different outcome measures, we suggest that care should be taken in interpreting and generalizing findings.

PROSPERO REGISTRATION

CRD42021277940.

Effects of tai chi on postural balance and quality of life among the elderly with gait disorders: A systematic review

BACKGROUND

Tai Chi is good for improving the physical fitness of older adults. But few studies have reported the effects of Tai Chi on the postural balance and quality of life of older adults with gait disorders.

OBJECTIVE

This review aimed to assess the influence of tai chi on postural stability and quality of life in older adults with abnormal gait.

METHOD

According to the literature retrieval principles, the works published from the inception date to May 2023 were retrieved, including the following databases: PubMed, Scopus, Web of Science, China National Knowledge Infrastructure, EBSCOhost, and Google Scholar. Subsequently, literature screening and quality assessment were performed.

RESULTS

A total of 16 randomized controlled trials were included in this study, Tai Chi intervention can affect populations with Parkinson's disease (PD), no exercise, mild cognitive impairment (MCI), chronic stroke, sedentary, fear of falling, or history of falling. Postural instability is associated with balance, gait, the Unified Parkinson's Disease Rating Scale Motor Subscale 3 (UPDRS III), mobility, lower body strength, and falls. Only two articles looked at quality of life. The Yang style is the most commonly used in the intervention. Nonetheless, most studies were performed on female participants, hence, more research on older male populations is needed.

CONCLUSION

Tai Chi intervention benefits postural balance in patients with gait disorders. 12 weeks is the most common intervention period for patients with gait disorders. The frequency of intervention is seven articles twice a week, and the intervention time is about 60 minutes. The Tai Chi intervention methods in this study involve Yang Style, Sun Style, Taoist Tai Chi, and Health Qigong Tai Chi, but the Yang Style Tai Chi intervention is the most widely used.

Determining an optimal posturography dataset to identify standing behaviors in the post-stroke subacute phase. Cross-sectional study

BACKGROUND

A key issue for posturography is the expression of robust results, in a simplified way. Most studies of individuals post-stroke concern the chronic phase, with small sample sizes.

OBJECTIVES

By reducing the number of posturographic indices, we aimed to determine an optimal dataset and understand typical postural behaviors in the subacute post-stroke phase.

METHODS

In this cross-sectional study ancillary to the DOBRAS cohort, individuals were assessed as soon they could complete a full posturography session (with and without vision) after a first hemispheric stroke. Body-weight distribution on the mediolateral (ML) axis, position of the center of pressure on the antero-posterior (AP) axis, and postural sway on both axes were computed. Balance ability in daily life was quantified with the Postural Assessment Scale for Stroke. Data were analyzed by principal component and hierarchical clustering analyses as well as multiple linear regression.

RESULTS

We enrolled 95 individuals (median age: 67.0 years [Q1; Q3 56.0; 72.0]; 68% males). Vision suppression had a marginal effect, only increasing postural sway. Regardless of the visual condition, posturographic behavior was captured by a set of 3 indices that explained almost all the information. One postural sway index (ML or AP) gave more information (48%) than both position indices (ML 26% and AP 15%). These 3 indices identified 3 standing behaviors: 1) stable and symmetric, 2) asymmetric, unstable, and positioned backward, and 3) very unstable and positioned forward. Balance ability in daily life was explained (49% of the information, 95%CI [35; 63]) by weight-bearing asymmetry and postural sway on the ML axis, which played an independent role (both p<10-5), with similar impact.

CONCLUSIONS

Three typical behaviors allow standing after stroke: described by only 3 posturographic indices. Weight-bearing asymmetry is not the primary parameter and should not be considered in isolation as an outcome. To increase the feasibility of posturography in the early subacute phase and to simplify evaluation sessions, trials could be limited to eyes open.

REGISTRATION

NCT03203109.

Reliability and minimal detectable change of body-weight distribution and body sway between right and left brain-damaged patients at a chronic stage

PURPOSE

To assess the reliability and minimal detectable change (MDC) of weight-bearing asymmetry (WBA) and body sway (BS) during "eyes open" (EO) and "eyes closed" (EC) conditions for those with right brain damage (RBD) and left brain damage (LBD) at a chronic stage.

METHODS

Sixteen RBD and 16 LBD patients participated in two sessions within 15 days, composed of two trials of 30 s using a double force platform. Intraclass correlation coefficient (ICC_2,1), the standard error of measurement (SEM), and MDC were calculated for WBA and BS (area and velocity of sway).

RESULTS

Reliability of WBA was excellent (>0.75) except for EC for LBD patients (low SEM was found). The condition of EC was similar to or less reliable than that of EO. The MDC of WBA was 5.4 and 7.3% for LBD and RBD patients, respectively. Velocity of sway should be favored over the area of sway due to better reliability, with an MDC of 9 and 13 mm/s for RBD and LBD patients, respectively.

CONCLUSIONS

Parameters related to WBA and BS were highly reliable, without a difference between RBD and LBD patients, but less so in the condition of EC, and could be used for clinical rehabilitation and/or research.Implications for rehabilitationWeight-bearing asymmetry (WBA) and body sway (BS) are highly reliable posturography parameters.Reliability of WBA/BS is similar among right brain damaged (RBD) and left brain damaged (LBD) patients.A change of 5-7% can be interpreted as significant for WBA for chronic stroke.The minimal detectable change in measures is slightly higher for RBD patients.

Exercise dosage to facilitate the recovery of balance, walking, and quality of life after stroke

Background

Although aerobic training (AT) and resistance training (RT) are recommended after stroke, the optimal dosage of these interventions and their effectiveness on balance, walking capacity, and quality of life (QoL) remain conflicting.

Objectives

Our study aimed to quantify the effects of different modes, dosages and settings of exercise therapy on balance, walking capacity, and QoL in stroke survivors.

Method

PubMed, CINHAL, and Hinari databases were searched for randomised controlled trials (RCTs) evaluating the effects of AT and RT on balance, walking, and QoL in stroke survivors. The treatment effect was computed by the standard mean differences (SMDs).

Results

Twenty-eight trials (n = 1571 participants) were included. Aerobic training and RT interventions were ineffective on balance. Aerobic training interventions were the most effective in improving walking capacity (SMD = 0.37 [0.02, 0.71], p = 0.04). For walking, capacity, a higher dosage (duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve) of AT interventions demonstrated a significantly greater effect (SMD = 0.58 [0.12, 1.04], p = 0.01). Combined AT and RT improved QoL (SMD = 0.56 [0.12, 0.98], p = 0.01). Hospital located rehabilitation setting was effective for improving walking capacity (SMD = 0.57 [0.06, 1.09], p = 0.03) compared with home and/or community and laboratory settings.

Conclusion

Our findings showed that neither AT nor RT have a significant effect on balance. However, AT executed in hospital-located settings with a higher dose is a more effective strategy to facilitate walking capacity in chronic stroke. In contrast, combined AT and RT is beneficial for improving QoL.

Clinical implications

A high dosage of aerobic exercise, duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve is beneficial for improving walking capacity.

Validity and reliability of center of pressure measures to quantify trunk control ability in individuals after stroke in subacute phase during unstable sitting test

Objective

The objective of this study was to assess, for individuals with hemiparesis after a stroke in subacute phase, the validity and reliability of center of pressure (CoP) parameters measured during sitting balance on an unstable support.

Materials and methods

Thirty-two individuals after stroke were included in this observational study for validity and reliability (mean age: 64.34 ± 9.30y, 23 men, mean post-stroke duration: 55.64 ± 27days). Intra-Class Correlation (ICC) and Bland Altman plot assessed intra-rater reliability and inter-rater reliability of CoP parameters during unstable sitting balance test (anteroposterior or mediolateral imbalance). Validity was established by correlating CoP parameters with the Modified Functional Reach Test, trunk strength, Balance Assessment in Sitting and Standing and Timed Up and Go tests.

Results

The findings highlighted significant correlations between CoP parameters and trunk strength for anteroposterior seated destabilization. Good to excellent intra and inter-rater reliability (0.87 ≤ ICC ≤ 0.95) was observed for all CoP length parameters and CoP mean velocity in both mediolateral and anteroposterior imbalance conditions. CoP parameters for mediolateral unstable sitting condition were more reliable than for anteroposterior instability.

Conclusion

Trunk control assessment during unstable sitting position on a seesaw is a reliable test for assessing trunk control ability in individuals after a stroke. CoP length and mean velocity are found to be the best parameters.

•

Center of pressure values during anteroposterior perturbation is related to trunk strength.

•

Center of pressure length parameters have excellent intra-rater and inter-rater reliability in individuals after a stroke in subacute phase.

•

The reliability is better when the sitting instability is in mediolateral direction.

The Use of Portable Devices for the Instrumental Assessment of Balance in Patients with Chronic Stroke: A Systematic Review

BACKGROUND

Improving balance remains a challenge in stroke rehabilitation. The technological development has allowed the design of more accessible and user-friendly systems for assessing postural control.

OBJECTIVES

The aim of this review was to analyze portable devices for the instrumental assessment of balance in patients with chronic stroke.

METHODS

PRISMA guidelines were used to carry out the systematic review. The literature search was restricted to articles written in English or Spanish published from 2013 to December 2022 in Pubmed, Web of Science, Scopus, PEDro, and CINAHL. Of the 309 search results, 229 unique references were reviewed after duplicates were removed. The PEDro scale was applied to evaluate the methodological quality of the included papers, and the degree of evidence and level of recommendation were determined through the Oxford Centre for Evidence-Based Medicine.

RESULTS

A total of seven articles reporting on five different balance testing devices were included in this systematic review; they regarded BIORescue, a smartphone application, and the Biodex-BioSway Balance System for the evaluation of standing balance, and SwayStar Balance and Xsens ForceShoes™ for the evaluation of dynamic balance during walking.

CONCLUSIONS

The use of portable devices that assess balance in adult patients with chronic stroke is scarce.

Efeitos da vibração do tendão muscular no equilíbrio após acidente vascular cerebral: revisão sistemática

RESUMO Após o acidente vascular cerebral (AVC), as pessoas apresentam combinações complexas de déficits sensoriais, motores, cognitivos e emocionais que podem afetar o equilíbrio estático e dinâmico. O objetivo do estudo foi compilar e resumir as principais características e achados de protocolos utilizados em pesquisas que investigaram os efeitos da vibração no tendão muscular no equilíbrio estático e dinâmico em adultos com AVC. Trata-se de uma revisão sistemática, registrada na PROSPERO (CRD42022303874), em que foram realizadas buscas nas bases de dados PubMed, Cochrane, LILACS, SciELO, MEDLINE, Science Direct e PEDro, durante o mês de janeiro de 2022, por meio da combinação de palavras-chave relacionadas a “stroke”, “balance”, “muscle tendon vibration” e “randomized controlled trial”. A qualidade metodológica foi avaliada através da escala PEDro. Foram identificados 1.560 estudos, dos quais 11 foram incluídos, publicados entre 1994 e 2020, envolvendo 242 adultos pós-AVC. Apenas cinco estudos utilizaram a vibração como intervenção e verificaram melhora no equilíbrio estático e dinâmico. Seis estudos analisaram a interferência da vibração no controle postural, observando que o equilíbrio foi afetado durante a aplicação da vibração e que os indivíduos precisaram de mais tempo para se recuperar ou não sofreram diferenças significativas. Verificou-se que os efeitos da vibração do tendão muscular podem melhorar o equilíbrio em pessoas com AVC e influenciar o controle postural através de mecanismos proprioceptivos da vibração. Entretanto, são necessários mais estudos de alta qualidade metodológica para atingir um consenso em relação aos protocolos de tratamento com vibração do tendão muscular e sua recomendação na prática clínica.

Effects of muscle tendon vibration on balance after stroke: systematic review

ABSTRACT After cerebrovascular accident (CVA), people have complex combinations of sensory, motor, cognitive, and emotional deficits, which can affect static and dynamic balance. This study aimed to compile and summarize the main features and findings of protocols used in research that investigated the effects of muscle tendon vibration on static and dynamic balance in adults with stroke. This is a systematic review, registered in PROSPERO (CRD42022303874), in which searches were performed in the databases PubMed, Cochrane, LILACS, SciELO, MEDLINE, Science Direct, and PEDro, during the month of January 2022, using the combination of keywords related to “stroke,” “balance,” “muscle tendon vibration,” “randomized controlled trial.” Methodological quality was assessed using the PEDro scale. A total of 1,560 studies were identified, 11 of which were included, between the years 1994 to 2020, involving 242 post-stroke adults. Only five studies used vibration as an intervention and found an improvement in static and dynamic balance. Six studies analyzed the interference of vibration on postural control, showing that balance was affected during the application of vibration and that individuals needed more time to recover or did not experience significant differences. We found that the effects of muscle tendon vibration may be able to improve balance in people with stroke and influence postural control by proprioceptive mechanisms of vibration. However, more studies of high methodological quality are needed to reach a consensus regarding muscle tendon vibration treatment protocols and their recommendation in clinical practice.

Brazilian practice guidelines for stroke rehabilitation: Part II

The Brazilian Practice Guidelines for Stroke Rehabilitation - Part II, developed by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, in Portuguese), focuses on specific rehabilitation techniques to aid recovery from impairment and disability after stroke. As in Part I, Part II is also based on recently available evidence from randomized controlled trials, systematic reviews, meta-analyses, and other guidelines. Part II covers disorders of communication, dysphagia, postural control and balance, ataxias, spasticity, upper limb rehabilitation, gait, cognition, unilateral spatial neglect, sensory impairments, home rehabilitation, medication adherence, palliative care, cerebrovascular events related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the future of stroke rehabilitation, and stroke websites to support patients and caregivers. Our goal is to provide health professionals with more recent knowledge and recommendations for better rehabilitation care after stroke.

Rehabilitation interventions of unilateral spatial neglect based on the functional outcome measure: A systematic review and meta-analysis

ABSTRACTThis review aimed to examine the bottom-up and top-down rehabilitation intervention effectiveness based on the functional outcome measure as immediate effect and long-term effect for unilateral spatial neglect conditions. The RCT studies were collected by searching in three databases J-Stage, PubMed, and PEDro from 2008 through 2018. The studies which used the following instruments: BI, CBS, FMA, and FIM, as the functional outcome with the PEDro score of six and above, were eligible for inclusion. A total of 492 participants in 13 studies included from 291 studies initially identified. The meta-analysis for overall ES revealed that BI and CBS had a significant mean of SMD = 0.65 (95% CI, 0.23-1.07; p = 0.003; I2 = 65%), and SMD = -0.23 (95% CI, -0.45 to -0.01; p = 0.04; I2 = 35%) respectively, while FMA and FIM had an insignificant mean of SMD = 0.14 (95% CI, -0.08-0.37; p = 0.22; I2 = 0%), and SMD = -0.22 (95% CI, -0.69-0.25; p = 0.37; I2 = 0%) respectively. Based on the results, although indicated the heterogeneity representation across studies, it showed that the top-down intervention approach of high-frequency rTMS was more effective in enhancing the functional abilities and ADL of unilateral spatial neglect patients on the immediate effects but not necessarily in the long-term effects.

Sex Differences in the Long-Term Consequences of Stroke

Stroke is the fifth leading cause of death and as healthcare intervention improves, the number of stroke survivors has also increased. Furthermore, there exists a subgroup of younger adults, who suffer stroke and survive. Given the overall improved survival rate, bettering our understanding of long-term stroke outcomes is critical. In this review we will explore the causes and challenges of known long-term consequences of stroke and if present, their corresponding sex differences in both old and young survivors. We have separated these long-term post-stroke consequences into three categories: mobility and muscle weakness, memory and cognitive deficits, and mental health and mood. Lastly, we discuss the potential of common preclinical stroke models to contribute to our understanding of long-term outcomes following stroke.

The effect of motor relearning on balance, mobility and performance of activities of daily living among post-stroke patients: Study protocol for a randomised controlled trial

BACKGROUND

Balance and gait impairments are the most common motor deficits due to stroke, limiting the patients' daily life activities and participation in society. Studies investigating effect of task-specific training using biomechanical balance and gait variables (i.e. kinetic and kinematic parameters) as well as posturography after stroke are scarce.

OBJECTIVES

The primary aim of this study is to assess the efficacy and long-term outcome of task-specific training based on motor relearning program (MRP) on balance, mobility and performance of activities of daily living among post-stroke patients.

METHODS

In this two-armed randomised controlled clinical trial, a total of 66 sub-acute stroke patients who meet the trial criteria will be recruited. The patients will randomly receive task-specific training based on MRP or a conventional physical therapy program (CPT). Twenty-four physiotherapy sessions will be conducted, divided into three training sessions per week, 1 h per session, for 8 weeks, followed by an analysis of changes in patient's balance, gait and performance of activates of daily living at three time periods; baseline, post-intervention and follow-up after 3-months, using clinical outcome measures and instrumental analysis of balance and gait.

DISCUSSION

The results of this study can guide to better understanding and provide an objective clinical basis for the use of task-specific training in stroke rehabilitation. Also, it intends to help bridge the current knowledge gap in rehabilitation and training recommendations to provide a therapeutic plan in post-stroke rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05076383). Registered on 13 October 2021 (Protocol version: v2.0).

The Application of Biological Feedback in the Rehabilitation of Patients after Ischemic Stroke

Balance disorders are the main concern for patients after an ischemic stroke. They are caused by an abnormal force on the affected side or paresis, which causes uneven loading and visuospatial disorders. Minimizing the effects of stroke is possible through properly conducted rehabilitation. One of the known ways to achieve this objective is biological feedback. The lack of proper muscle tone on one side of the body is manifested by the uneven pressure of the lower extremities on the ground. The study and control groups were composed of two equal groups of 92 people each, in which the same set of kinesiotherapeutic exercises were applied. Patients in the study group, in addition to standard medical procedures, exercised five days a week on a Balance Trainer for four weeks. The examination and training with the device were recorded on the first day of rehabilitation, as well as after two and four weeks of training. The assessment was performed using the following functional tests and scales: Brunnström, Rankin, Barthel, Ashworth, and VAS. Patients in the control group started exercising on the Balance Trainer two weeks after the first day of rehabilitation using traditional methods. The study results reveal statistically significant reductions in the time the body’s center of gravity (COG) spent in the tacks, outside the tracks and in the COG distance, lower COG excursions in all directions. Post-stroke patients that received biofeedback training presented significantly better results than patients that did not receive such training.

Effects of prismatic adaptation on balance and postural disorders in patients with chronic right stroke: protocol for a multicentre double-blind randomised sham-controlled trial

INTRODUCTION

Patients with right stroke lesion have postural and balance disorders, including weight-bearing asymmetry, more pronounced than patients with left stroke lesion. Spatial cognition disorders post-stroke, such as misperceptions of subjective straight-ahead and subjective longitudinal body axis, are suspected to be involved in these postural and balance disorders. Prismatic adaptation has showed beneficial effects to reduce visuomotor disorders but also an expansion of effects on cognitive functions, including spatial cognition. Preliminary studies with a low level of evidence have suggested positive effects of prismatic adaptation on weight-bearing asymmetry and balance after stroke. The objective is to investigate the effects of this intervention on balance but also on postural disorders, subjective straight-ahead, longitudinal body axis and autonomy in patients with chronic right stroke lesion.

METHODS AND ANALYSIS

In this multicentre randomised double-blind sham-controlled trial, we will include 28 patients aged from 18 to 80 years, with a first right supratentorial stroke lesion at chronic stage (≥12 months) and having a bearing ≥60% of body weight on the right lower limb. Participants will be randomly assigned to the experimental group (performing pointing tasks while wearing glasses shifting optical axis of 10 degrees towards the right side) or to the control group (performing the same procedure while wearing neutral glasses without optical deviation). All participants will receive a 20 min daily session for 2 weeks in addition to conventional rehabilitation. The primary outcome will be the balance measured using the Berg Balance Scale. Secondary outcomes will include weight-bearing asymmetry and parameters of body sway during static posturographic assessments, as well as lateropulsion (measured using the Scale for Contraversive Pushing), subjective straight-ahead, longitudinal body axis and autonomy (measured using the Barthel Index).

ETHICS AND DISSEMINATION

The study has been approved by the ethical review board in France. Findings will be submitted to peer-reviewed journals relative to rehabilitation or stroke.

TRIAL REGISTRATION NUMBER

NCT03154138.

Factors associated with balance impairments amongst stroke survivors in northern Benin: A cross-sectional study

Background

Balance impairment is the predominant risk factor for falls in stroke survivors. A fear of falling after stroke can contribute to sedentary lifestyles, increased disability and risk of recurrence, leading to poor quality of life.

Objective

To determine the frequency and factors associated with balance impairments amongst stroke survivors at the University Hospital of Parakou.

Method

This cross-sectional study included adult stroke survivors. Stroke survivors after discharge were enrolled at the University Hospital of Parakou between 01 January 2020 and 30 September 2020. Balance impairments were measured by using the Berg Balance Scale (BBS), the Timed Up and Go (TUG) and the Get Up and Go (GUG) tests.

Results

A total of 54 stroke survivors were included, with a mean age of 58.37 ± 12.42 years and a male predominance of 68.52%. The mean BBS score was 36.87 ± 14.34 with a minimum and a maximum of 10 and 56, respectively. Thirteen (24.07%) had balance impairments (BBS score ≤ 20), 34 (62.96%) had a TUG score ≥ 14 s (abnormal), 9 (16.67%) presented a moderate risk of falling and 6 (11.11%) presented high risk of fall with the GUG test. Post-stroke duration (odds ratio [OR] = 0.04; 95% CI: 0.04–0.30; p < 0.01), severity of disability (OR = 8.33; 95% CI: 1.03–67.14; p = 0.03) and the number of physiotherapy sessions (OR = 0.18; 95% CI: 0.03–0.93; p = 0.02) were significantly associated with balance impairments.

Conclusion

Our results showed that almost one quarter of stroke survivors after discharge at the University Hospital of Parakou had balance impairments. Post-stroke duration, severity of disability and the number of physiotherapy sessions were significantly associated with balance impairments.

Clinical implications

[AQ1] Balance should be regularly assessed in people post-stroke. Further studies should document the content of rehabilitation and any rehabilitative efforts to improve balance in people post-stroke in Benin.

Combination of Stem Cells and Rehabilitation Therapies for Ischemic Stroke

Stem cell transplantation with rehabilitation therapy presents an effective stroke treatment. Here, we discuss current breakthroughs in stem cell research along with rehabilitation strategies that may have a synergistic outcome when combined together after stroke. Indeed, stem cell transplantation offers a promising new approach and may add to current rehabilitation therapies. By reviewing the pathophysiology of stroke and the mechanisms by which stem cells and rehabilitation attenuate this inflammatory process, we hypothesize that a combined therapy will provide better functional outcomes for patients. Using current preclinical data, we explore the prominent types of stem cells, the existing theories for stem cell repair, rehabilitation treatments inside the brain, rehabilitation modalities outside the brain, and evidence pertaining to the benefits of combined therapy. In this review article, we assess the advantages and disadvantages of using stem cell transplantation with rehabilitation to mitigate the devastating effects of stroke.

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.

The Effectiveness of Additional Core Stability Exercises in Improving Dynamic Sitting Balance, Gait and Functional Rehabilitation for Subacute Stroke Patients (CORE-Trial): Study Protocol for a Randomized Controlled Trial

Background: Trunk impairment produces disorders of motor control, balance and gait. Core stability exercises (CSE) are a good strategy to improve local strength of trunk, balance and gait. Methods and analysis: This is a single-blind multicenter randomized controlled trial. Two parallel groups are compared, and both perform the same type of therapy. A control group (CG) (n = 110) performs conventional physiotherapy (CP) (1 h per session) focused on improving balance. An experimental group (EG) (n = 110) performs CSE (30 min) in addition to CP (30 min) (1 h/session in total). EG is divided in two subgroups, in which only half of patients (n = 55) perform CSE plus transcutaneous electrical nerve stimulation (TENS). Primary outcome measures are dynamic sitting, assessed by a Spanish version of Trunk Impairment Scale and stepping, assessed by Brunel Balance Assessment. Secondary outcomes are postural control, assessed by Postural Assessment Scale for Stroke patients; standing balance and risk of fall assessed by Berg Balance Scale; gait speed by BTS G-Walk (accelerometer); rate of falls, lower-limb spasticity by Modified Ashworth Scale; activities of daily living by Barthel Index; and quality of life by EQ-5D-5L. These are evaluated at baseline (T0), at three weeks (T1), at five weeks (end of the intervention) (T2), at 17 weeks (T3) and at 29 weeks (T4). Study duration per patient is 29 weeks (a five-week intervention, followed by a 24-week post-intervention).

Effectiveness of hippotherapy and therapeutic horseback riding on balance in hemiparetic patients after stroke

Abstract Introduction: Stroke is one of the leading causes of disability and death worldwide. Individuals who suffered stroke present numerous functional limitations. Hippo-therapy (HPOT) is proposed as capable of promoting the recovery of postural balance in patients with neurological impairment. Objective: To analyze published articles, seeking the effects of HPOT on changes in postural balance, through the Berg Balance Scale (BBS), in individuals with stroke. Methods: We conducted a systematic review and meta-analysis of studies published on the electronic databases PubMed, VHL, SCIELO, Cochrane, SCOPUS, WoS, and Cinahl. Keywords: "hippotherapy", "horseback riding" and "stroke" linked by the OR and AND boolean operators. The research was restricted to clinical trials in an adult population with a history of stroke. Results: Four articles were included in this meta-analysis, which used HPOT as an intervention to improve postural balance. Three studies used a mechanical device (horseback riding), and the horse. The age ranged from 61 to 71 years, being more predominant the male sex. Sessions ranged from 6 to 12 weeks of 20 to 30 minutes per session. Quality analysis using the PEDro scale demonstrated scores ranging from 6 to 8 points in the selected studies. Overall, treatment with mechanical and conventional therapy resulted in an improvement in the total BBS score. As compared with conventional therapy just studies with horseback riding was superior to conventional therapy to improve postural balance in hemiparetic stroke patients. Conclusion: There are few studies of high quality; then, it is not possible to evaluate the effectiveness of HPOT using a horse or a mechanic simulator in patients with stroke when compared with conventional therapy. Future studies could clarify if HPOT has potential benefits as a complementary therapeutic strategy to conventional physiotherapy to promote the improvement of postural balance after stroke.

Does Exercise-Based Conventional Training Improve Reactive Balance Control among People with Chronic Stroke?

Background: Exercise-based conventional training has predominantly benefited fall-associated volitional balance control domain; however, the effect on reactive balance control is under-examined. Therefore, the purpose of this study was to examine the effect of exercise-based conventional training on reactive balance control. Methods: Eleven people with chronic stroke (PwCS) underwent multi-component training for six weeks (20 sessions) in a tapering manner. Training focused on four constructs-stretching, functional strengthening, balance, and endurance. Volitional balance was measured via movement velocity on the Limits of Stability (LOS) test and reactive balance via center of mass (COM) state stability on the Stance Perturbation Test (SPT). Additionally, behavioral outcomes (fall incidence and/or number of steps taken) were recorded. Results: Movement velocity significantly increased on the LOS test (p < 0.05) post-intervention with a significant decrease in fall incidence (p < 0.05). However, no significant changes were observed in the COM state stability, fall incidence and number of recovery steps on the SPT post-intervention. Conclusion: Although volitional and reactive balance control may share some neurophysiological and biomechanical components, training based on volitional movements might not significantly improve reactive balance control for recovery from large-magnitude perturbations due to its task-specificity.

Video Game-Based Therapy on Balance and Gait of Patients with Stroke: A Systematic Review

Background: Stroke patients with motor, sensory and cognitive diseases can take profits from information and communication technologies—in particular, from the latest commercial video consoles, which are based on motion capture. These technologies are positioning themselves as complementary therapeutic tools for treating gait and balance disorders. In this paper, a systematic review of the effect of video game-based therapy on balance and gait in stroke patients is shown and compared with other types of treatments. Methods: A systematic review of prospective controlled clinical trials published in the main biomedical databases in English and Spanish between 2005 and 2020 was performed. The systematic review presented in this paper has been done following the Cochrane Manual recommendations and the PRISMA Declaration by two independent reviewers. Data about participants, intervention, outcome measurements and outcome measurement results were extracted. The quality of evidence of each study was assessed using Cochrane’s standard quality assessment format, which includes a description of the risk of bias. Additionally, the Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of each paper. Results: A total of 18 papers, including 479 patients, were included in this systematic review, in which the use of video consoles (in combination with conventional rehabilitation or exclusively) was compared with conventional rehabilitation to treat balance or gait in post-stroke patients. In all studies, a tendency to improve balance was found in both intervention groups, finding, in 10 of 17 studies that analysed it, a better capacity in the experimental group that included video consoles compared to the conventional rehabilitation control group. Regarding gait, in six of seven studies that analysed it, improvements were found in both intervention groups, and these improvements were greater in the experimental group than compared to the control group in three of them. Conclusions: Commercial video game systems, in combination with conventional rehabilitation, have shown positive results on balance and gait in post-stroke patients. There were variations between the trials in terms of the video consoles used and the duration, frequency and number of sessions with commercial video games. Future studies should compare the effects of commercial video game treatments on balance and gait in stroke patients with a nonintervention group to know their real efficacy.

Publication language and the estimate of treatment effects of physical therapy on balance and postural control after stroke in meta-analyses of randomised controlled trials

BACKGROUND

Findings regarding the impact of language bias on treatment effect estimates (TEE) are conflicting, and very few studies have assessed these impacts in rehabilitation. The purpose was to compare TEE between studies published in non-English language (SPNEL) and those published in English language (SPEL) included in a previously published meta-analysis assessing the effects of physical therapy on balance and postural control after stroke.

METHODS

Six databases were searched until January 2019. Two independent reviewers selected randomised trials, extracted data, and assessed risk of bias. We conducted subgroup meta-analyses according to the language of study publication, then compared TEE between SPEL and SPNEL subgroups by using a random-effects meta-regression model.

RESULTS

From 13,123 records, 132 SPEL (n = 5219) and 13 SPNEL (n = 693) were included. SPNEL had a weight in the pooled estimate (8.2%) significantly lower than SPEL (91.8%; p<0.001). Compared to SPEL, SPNEL had both significantly worse methodological quality (p = 0.002) and quality of reporting for blinding of outcome assessment (p<0.001); and a significantly worse quality of reporting for incomplete outcome data (p<0.001). SPNEL had a significantly worse precision (i.e. inverse of variance) of TEE than SPEL (p = 0.005). Overall, the TEE was not significantly different between SPNEL and SPEL (standardised mean difference -0.16, 95% confidence interval [-0.53; 0.22], heterogeneity I2 = 78%). However, when PT was compared to sham treatment or usual care, SPNEL significantly over-estimated treatment effects (SMD -0.68, 95%CI [-1.03; -0.33], I2 = 39%) compared to SPEL. Restriction of the search to SPEL only did not change the direction of TEE for 8 out of 9 comparisons.

CONCLUSIONS

SPNEL had a worse methodological quality than SPEL and were likely to over-estimate treatment effect. If inclusion of SPNEL in a systematic review is considered to be relevant, the impact of such studies on TEE should be explored by sensitivity analyses to ensure the findings validity.

Acupuncture of fascia points to relieve hand spasm after stroke: a study protocol for a multicenter randomized controlled trial

Background

The loss of functional ability of patients after stroke is mostly caused by dysfunction of the upper limbs, especially the hands. Hand functional exercise is the premise of alleviating hand dysfunction, and the relief of hand spasm is the basis of timely and effective hand functional exercise. Previous clinical observation have shown that fascial-point needling can effectively alleviate hand spasm immediately after stroke, but further evidence from large-sample studies is needed. The overall objective of this trial is to further evaluate the clinical efficacy of fascial-point acupuncture on hand spasm after stroke.

Methods/design

This multicenter randomized controlled trial will compare the efficacy of fascial-point acupuncture versus sham acupuncture and routine rehabilitation therapy in stroke patients with hand spasm. Patients will be randomized to undergo either the fascial-point acupuncture, the sham acupuncture or the control (routine rehabilitation therapy). We will recruit 210 stroke inpatients who meet the trial criteria and observe the remission of hand spasm and improvement of limb function after 4 weeks of intervention. The first evaluation indices are the remission of hand spasm and the duration of spasm remission. The second evaluation indices are the hand function of the affected limbs and the activities of daily living. When the accumulative total number of cases included reaches 120, a mid-term analysis will be conducted to determine any evidence that experimental intervention does have an advantage.

Discussion

Our aim is to evaluate the efficacy of fascial-point acupuncture in relieving hand spasm after stroke. The results should provide more evidence for the clinical application of this therapy in the future.

Trial registration

Chinese Clinical Trial Registry (ChiCTR), ID: ChiCTR1900022379. Registered on 9 April 2019