Physiotherapy and physical functioning post-stroke: Exercise habits and functioning 4 years later? Long-term follow-up after a 1-year long-term intervention period: A randomized controlled trial

Effectiveness of kinesio taping for chronic stroke patients: a systematic review with meta-analysis

PURPOSE

Kinesio taping (KT) is an approach that has been used in the rehabilitation of patients with chronic stroke. The aim of this review is to evaluate the effectiveness of KT alone or combined with other interventions for patients with chronic stroke.

MATERIALS AND METHODS

The search was performed on CENTRAL, EMBASE, PEDro, and five other databases and two trial registries up to July 2022. We included randomized controlled trials that evaluated the effectiveness of KT compared to control interventions. The primary outcomes were upper limb function and gait. We assessed the risk of bias in the included studies using the PEDro scale. The certainty of the evidence was assessed using the GRADE approach.

RESULTS

We included 14 RCTs undertaken in six different countries. PEDro score ranged from 4 to 9 points. There is very-low certainty evidence that KT has no effect on gait, balance, and postural control. We found very-low certainty evidence of a slightly benefit when used in addition to other therapies for gait, balance and postural control, and pain intensity.

CONCLUSIONS

Our study findings show KT does not have enough robust evidence for improving upper limb function, gait, balance and postural control, and pain intensity in chronic stroke patients.

Stroke Recovery Is a Journey: Prediction and Potentials of Motor Recovery after a Stroke from a Practical Perspective

Stroke recovery is a journey. Stroke survivors can face many consequences that may last the rest of their lives. Assessment of initial impairments allows reasonable prediction of biological spontaneous recovery at 3 to 6 months for a majority of survivors. In real-world clinical practice, stroke survivors continue to improve their motor function beyond the spontaneous recovery period, but management plans for maximal recovery are not well understood. A model within the international classification of functioning (ICF) theoretical framework is proposed to systematically identify opportunities and potential barriers to maximize and realize the potentials of functional recovery from the acute to chronic stages and to maintain their function in the chronic stages. Health conditions of individuals, medical and neurological complications can be optimized under the care of specialized physicians. This permits stroke survivors to participate in various therapeutic interventions. Sufficient doses of appropriate interventions at the right time is critical for stroke motor rehabilitation. It is important to highlight that combining interventions is likely to yield better clinical outcomes. Caregivers, including family members, can assist and facilitate targeted therapeutic exercises for these individuals and can help stroke survivors comply with medical plans (medications, visits), and provide emotional support. With health optimization, comprehensive rehabilitation, support from family and caregivers and a commitment to a healthy lifestyle, many stroke survivors can overcome barriers and achieve potentials of maximum recovery and maintain their motor function in chronic stages. This ICF recovery model is likely to provide a guidance through the journey to best achieve stroke recovery potentials.

Associations of grip strength and walking pace with mortality in stroke survivors: A prospective study from UK Biobank

INTRODUCTION

Although stroke is an emerging cause of disability and mortality globally, associations between physical capability markers and mortality in stroke survivors are elusive. This study investigated the individual and combined associations of walking pace and grip strength with all-cause and stroke mortality in stroke survivors.

METHODS

Individual and combined associations of walking pace and grip strength with stroke deaths and all-cause mortality were investigated using Cox proportional-hazard models adjusted for sociodemographic, lifestyle, and health-related variables.

RESULTS

Seven thousand four hundred eighty-six stroke survivors from the UK Biobank study (aged 40-70 years; 42.4% women) were included in this prospective study. Over a median follow-up of 12.6 (IQR: 11.9-13.3) years, 1490 (19.9%) participants died, of whom 222 (3.0%) died from stroke. After adjusting for confounding factors, and compared to individuals in the average/brisk walking pace category, those who reported a slow walking pace had 2.00 (95% CI: 1.50-2.68) and 1.99 (95% CI: 1.78-2.23) times higher risk of stroke mortality and all-cause mortality, respectively. Similar associations were identified for participants with low grip strength compared with those with normal levels. For combined associations, those with both slow walking pace and low grip strength showed the highest risk of stroke mortality (hazard ratio: 2.86 [95% CI: 1.93-4.22]). Similar results were found for all-cause mortality.

CONCLUSIONS

Low grip strength and slow walking pace were associated with a higher risk of stroke and all-cause mortality in stroke survivors. If these associations are causal, improving physical capability among stroke survivors might potentially prolong survival.

Effect of a tailored upper extremity strength training intervention combined with direct current stimulation in chronic stroke survivors: A Randomized Controlled Trial

Strengthening exercises are recommended for managing persisting upper limb (UL) weakness following a stroke. Yet, strengthening exercises often lead to variable gains because of their generic nature. For this randomized controlled trial (RCT), we aimed to determine whether tailoring strengthening exercises using a biomarker of corticospinal integrity, as reflected in the amplitude of motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation (TMS), could optimize training effects in the affected UL. A secondary aim was to determine whether applying anodal transcranial direct current stimulation (tDCS) could enhance exercise-induced training effects. For this multisite RCT, 90 adults at the chronic stage after stroke (>6 months) were recruited. Before training, participants underwent TMS to detect the presence of MEPs in the affected hand. The MEP amplitude was used to stratify participants into three training groups: (1) low-intensity, MEP <50 μV, (2) moderate-intensity, 50 μV < MEP < 120 μV, and (3) high-intensity, MEP>120 μV. Each group trained at a specific intensity based on the one-repetition maximum (1 RM): low-intensity, 35–50% 1RM; moderate-intensity, 50–65% 1RM; high-intensity, 70–85% 1RM. The strength training targeted the affected UL and was delivered 3X/week for four consecutive weeks. In each training group, participants were randomly assigned to receive either real or sham anodal tDCS (2 mA, 20 min) over the primary motor area of the affected hemisphere. Pre-/post-intervention, participants underwent a clinical evaluation of their UL to evaluate motor impairments (Fugl-Meyer Assessment), manual dexterity (Box and Blocks test) and grip strength. Post-intervention, all groups exhibited similar gains in terms of reduced impairments, improved dexterity, and grip strength, which was confirmed by multivariate and univariate analyses. However, no effect of interaction was found for tDCS or training group, indicating that tDCS had no significant impact on outcomes post-intervention. Collectively, these results indicate that adjusting training intensity based on the size of MEPs in the affected extremity provides a useful approach to optimize responses to strengthening exercises in chronic stroke survivors. Also, the lack of add-on effects of tDCS applied to the lesioned hemisphere on exercise-induced improvements in the affected UL raises questions about the relevance of combining such interventions in stroke.

Exercise for Stroke Rehabilitation: A Bibliometric Analysis of Global Research From 2001 to 2021

Objective

To make a bibliometric analysis of global trends in research into exercise interventions for stroke between 2001 and 2021.

Method

This study did the systematic literature from 2001 to 2021 in Web of Science Core Collection. CiteSpace software was used to analyze the relationship of publications with countries, journals, authors, references, and keywords.

Results

A total of 3,484 publications were obtained in the bibliometric analysis. The number of publications increased gradually over the period. The United States have the most number of publications. The journal stroke had the most citations per paper (106.95) and the highest impact factor (IF 2020, 7.194). The most high frequency keywords are “stroke,” “rehabilitation,” and “recovery,” the top of burst key words are “health,” “speed,” and “aerobic exercise”.

Conclusion

These findings provide the trends of exercise for stroke s and provided the potential research frontiers in the past 20 years. It will be a useful basis for further research into focus issues, cooperators, development trends.

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.

Developing and validating an accelerometer-based algorithm with machine learning to classify physical activity after acquired brain injury

Purpose: To develop and validate an accelerometer-based algorithm classifying physical activity in people with acquired brain injury (ABI) in a laboratory setting resembling a real home environment.Materials and methods: A development and validation study was performed. Eleven healthy participants and 25 patients with ABI performed a protocol of transfers and ambulating activities. Activity measurements were performed with accelerometers and with thermal video camera as gold standard reference. A machine learning-based algorithm classifying specific physical activities from the accelerometer data was developed and cross-validated in a training sample of 11 healthy participants. Criterion validity of the algorithm was established in 3 models classifying the same protocol of activities in people with ABI.Results: Modeled on data from 11 healthy and 15 participants with ABI, the algorithm had a good precision for classifying transfers and ambulating activities in data from 10 participants with ABI. The weighted sensitivity for all activities was 89.3% (88.3-90.4%) and the weighted positive predictive value was 89.7% (88.7-90.7%). The algorithm differentiated between lying and sitting activities.Conclusion: An algorithm to classify physical activities in populations with ABI was developed and its criterion validity established. Further testing of precision in home settings with continuous activity monitoring is warranted.

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.

Exercise Programs Delivered According to Guidelines Improve Mobility in People With Stroke: A Systematic Review and Meta-analysis

OBJECTIVE

To determine if prescribing a combined aerobic and resistance training exercise program in accordance with American Stroke Association physical activity guidelines improves mobility and physical activity levels of people after stroke.

DATA SOURCES

Online database search from earliest available date to August 27, 2018.

STUDY SELECTION

Randomized controlled trials evaluating the effectiveness of exercise programs prescribed in accordance with guidelines for improving mobility and physical activity levels in adults with subacute or chronic stroke.

DATA EXTRACTION

Two independent reviewers completed data extraction. Risk of bias was assessed using the Physiotherapy Evidence Database Scale, and overall quality of evidence was assessed using the Grades of Research, Assessment, Development, and Evaluation approach.

DATA SYNTHESIS

Data was pooled from a total of 499 participants for meta-analysis. There was high-level evidence that exercise programs adhering to guidelines improve habitual walking speed (mean difference, 0.07m/s; 95% CI, -0.01 to 0.16) and walking endurance (mean difference, 39.2m, 95% CI, 17.2-61.2). A sensitivity analysis demonstrated high-level evidence of improvements in walking endurance (mean difference, 51.1m; 95% CI, 19.96-82.24) and moderate-level evidence of improvements on the Timed Up and Go test (standardized mean difference, 0.57; 95% CI, 0.16-0.99). No differences were detected for other mobility outcome measures or physical activity levels. Adherence was high and few adverse events were reported.

CONCLUSION

A combined exercise program comprising aerobic and resistance training that adheres to the American Stroke Association guidelines is safe and should be prescribed in addition to usual care to improve mobility. Further research is needed to understand the relationship between exercise programs and behavior change requirements to improve long-term physical activity levels.

A follow-up study of the effect of training using the Hybrid Assistive Limb on Gait ability in chronic stroke patients

Objectives: Recently, use of the Hybrid Assistive Limb (HAL) that is effective for improvement of gait ability in chronic stroke patients has been reported. However, how long the effects are maintained remains unknown. The purpose of the present study was to investigate whether the effect of gait training using the HAL on gait ability was maintained for 3 months after the intervention. Methods: A longitudinal, observational study with an intervention for a single group that adhered to the STROBE guidelines was performed. Nine chronic stroke patients were enrolled in this study. The patients performed gait training sessions using the HAL, 2-5 sessions/week for 3 weeks. Gait speed, stride length, cadence, and 2-minute walk distance (2MWD) were measured before and after intervention and at 3-month follow-up. The clinical trial registration number of this study is UMIN000012764 R000014756. Results: Compared to the initial status, gait speed (p = .02), stride length (p = .03), cadence (p = .01), and 2MWD (p < .05) were significantly increased immediately after the intervention. Moreover, gait speed (p < .01), cadence (p = .03), and 2MWD (p = .02) remained significantly higher 3 months after the intervention. There were no significant changes in all outcome measures between after intervention and at 3-month follow-up. Conclusions: This study showed that gait training using the HAL resulted in significant improvement of gait ability after the intervention and the effect was maintained for 3 months after the training.

Guided Self-rehabilitation Contract vs conventional therapy in chronic stroke-induced hemiparesis: NEURORESTORE, a multicenter randomized controlled trial

Background

After discharge from hospital following a stroke, prescriptions of community-based rehabilitation are often downgraded to “maintenance” rehabilitation or discontinued. This classic therapeutic behavior stems from persistent confusion between lesion-induced plasticity, which lasts for the first 6 months essentially, and behavior-induced plasticity, of indefinite duration, through which intense rehabilitation might remain effective. This prospective, randomized, multicenter, single-blind study in subjects with chronic stroke-induced hemiparesis evaluates changes in active function with a Guided Self-rehabilitation Contract vs conventional therapy alone, pursued for a year.

Methods

One hundred and twenty four adult subjects with chronic hemiparesis (> 1 year since first stroke) will be included in six tertiary rehabilitation centers. For each patient, two treatments will be compared over a 1-year period, preceded and followed by an observational 6-month phase of conventional rehabilitation. In the experimental group, the therapist will implement the diary-based and antagonist-targeting Guided Self-rehabilitation Contract method using two monthly home visits. The method involves: i) prescribing a daily antagonist-targeting self-rehabilitation program, ii) teaching the techniques involved in the program, iii) motivating and guiding the patient over time, by requesting a diary of the work achieved to be brought back by the patient at each visit. In the control group, participants will benefit from conventional therapy only, as per their physician’s prescription.

The two co-primary outcome measures are the maximal ambulation speed barefoot over 10 m for the lower limb, and the Modified Frenchay Scale for the upper limb. Secondary outcome measures include total cost of care from the medical insurance point of view, physiological cost index in the 2-min walking test, quality of life (SF 36) and measures of the psychological impact of the two treatment modalities. Participants will be evaluated every 6 months (D1/M6/M12/M18/M24) by a blinded investigator, the experimental period being between M6 and M18. Each patient will be allowed to receive any medications deemed necessary to their attending physician, including botulinum toxin injections.

Discussion

This study will increase the level of knowledge on the effects of Guided Self-rehabilitation Contracts in patients with chronic stroke-induced hemiparesis.

Trial registration

ClinicalTrials.gov: NCT02202954, July 29, 2014.

Cardiorespiratory fitness and walking endurance improvements after 12 months of an individualised home and community-based exercise programme for people after stroke

OBJECTIVE

To evaluate the immediate and longer-term effects of an individually tailored, home- and community-based exercise programme with ongoing remote support in people with stroke on cardiorespiratory fitness (CRF), ambulation and health-related quality of life (HRQoL).

METHODS

Twenty people 5.3 ± 3.5 months post stroke completed the 12-week HowFITSS? exercise programme aimed at increasing CRF and daily physical activity. Support was provided by phone and email, which decreased in frequency over time. Participants were assessed at baseline, then at 3, 6 and 12 months after initiation of the intervention. CRF (VO_2peak) was evaluated using a portable metabolic system during the 6-minute walk test (6MWT), the Shuttle Walk Test (SWT) and the cycle graded exercise test (cGXT). Walking speed, balance, body composition, fatigue, depression and HRQoL were also measured.

RESULTS

CRF improved significantly from pre-intervention to 12-month follow-up on the 6MWT (Effect Size, ES = 0.87; p = 0.002) and cGXT (ES = 0.60; p < 0.001), with more modest improvements on the SWT (ES = 0.52; p = 0.251). From baseline to 12 months, significant within-participant improvements were found for self-selected walking speed, balance and HRQoL. Performances on the remaining tests were maintained over the post-intervention period.

CONCLUSION

There may be health benefits of providing people with stroke an exercise intervention with long-term support that encourages increased regular physical activity.

Physical activity promotion in physiotherapy practice: a systematic scoping review of a decade of literature

Background

The health benefits of physical activity (PA) have been extensively documented. Globally PA levels are low with only a small proportion of the population reaching recommended levels. Insufficient PA is seen as a major public health problem with high cost to society. Physiotherapists work with people to manage long-term conditions and are well placed to deliver individual interventions to increase PA. Despite this, little is known about the evidence that exists in this field.

Methods

This scoping review comprises a comprehensive search of key databases using predetermined search terms. This is supplemented with a parallel search that incorporated novel social media strands. In line with current guidance, a robust screening process took place using agreed inclusion and exclusion criteria.

Results

31 studies met the inclusion criteria. The number of studies published annually increased over the decade. Ireland and USA yielded the largest number of publications with only 1 study from the UK. The target populations included physiotherapists and service users from a range of clinical populations. The studies were mainly quantitative and observational in design with a predominance of studies that scoped attitudes, perceptions, barriers and current practice.

Conclusions

This reconnaissance has shown the state of the evidence to be sparse and disparate. However, the sharp rise in published work in recent years is encouraging. The predominance of scoping studies and the clear social, economic and political drivers for change in this area highlights a need for more pragmatic, interventional studies that can inform clinical practice.

Lifestyle modification for stroke prevention: facts and fiction

PURPOSE OF REVIEW

The purpose is to summarize recent evidence on lifestyle modifications and first or recurrent stroke risk.

RECENT FINDINGS

Weight reduction, low-risk diet, regular physical activity, smoking cessation, and low-to-moderate alcohol consumption may reduce stroke risk up to 50% or more, but level one evidence is still lacking for several interventions. Appropriate food ingredients can significantly decrease stroke risk as recently confirmed for Mediterranean diet. The optimal intensity and amount of physical exercise is still not well established before and after stroke, although modest levels of activity already show benefits. Passive smoking represents an important health hazard. The impact of tobacco withdrawal using e-cigarette is currently uncertain. Alcohol and stroke risk relation is probably J-shaped for ischaemic stroke and linear for intracranial haemorrhage. Coffee consumption is J-shaped for overall stroke. Several interventions have failed to show significant effects, including regular intake of 'healthy' forms of fatty acids, various vitamin supplements, and other antioxidants. Both individualized and public educational programmes are likely needed on a repetitive basis to induce and maintain a healthy lifestyle before or after a stroke.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability.

OBJECTIVES

To determine whether fitness training after stroke reduces death, dependence, and disability and to assess the effects of training with regard to adverse events, risk factors, physical fitness, mobility, physical function, quality of life, mood, and cognitive function. Interventions to improve cognitive function have attracted increased attention after being identified as the highest rated research priority for life after stroke. Therefore we have added this class of outcomes to this updated review.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 1: searched February 2015), MEDLINE (1966 to February 2015), EMBASE (1980 to February 2015), CINAHL (1982 to February 2015), SPORTDiscus (1949 to February 2015), and five additional databases (February 2015). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 58 trials, involving 2797 participants, which comprised cardiorespiratory interventions (28 trials, 1408 participants), resistance interventions (13 trials, 432 participants), and mixed training interventions (17 trials, 957 participants). Thirteen deaths occurred before the end of the intervention and a further nine before the end of follow-up. No dependence data were reported. Diverse outcome measures restricted pooling of data. Global indices of disability show moderate improvement after cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) 0.19 to 0.84; P value = 0.002) and by a small amount after mixed training (SMD 0.26, 95% CI 0.04 to 0.49; P value = 0.02); benefits at follow-up (i.e. after training had stopped) were unclear. There were too few data to assess the effects of resistance training.Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 6.71 metres per minute, 95% CI 2.73 to 10.69), preferred gait speed (MD 4.28 metres per minute, 95% CI 1.71 to 6.84), and walking capacity (MD 30.29 metres in six minutes, 95% CI 16.19 to 44.39) at the end of the intervention. Mixed training, involving walking, increased preferred walking speed (MD 4.54 metres per minute, 95% CI 0.95 to 8.14), and walking capacity (MD 41.60 metres per six minutes, 95% CI 25.25 to 57.95). Balance scores improved slightly after mixed training (SMD 0.27, 95% CI 0.07 to 0.47). Some mobility benefits also persisted at the end of follow-up. The variability, quality of the included trials, and lack of data prevents conclusions about other outcomes and limits generalisability of the observed results.

AUTHORS' CONCLUSIONS

Cardiorespiratory training and, to a lesser extent, mixed training reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve the speed and tolerance of walking; some improvement in balance could also occur. There is insufficient evidence to support the use of resistance training. The effects of training on death and dependence after stroke are still unclear but these outcomes are rarely observed in physical fitness training trials. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription and identify long-term benefits.