No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Treadmill training in early poststroke patients - Do timing and walking ability matter?
Abstract
The restitution of gait is a major challenge during the rehabilitation of hemiparetic patients. We investigated the influence of three weeks of treadmill training combined with physiotherapy, 30 minutes daily, followed by three weeks physiotherapy 30 minutes twice per day and vice versa. Patients were included early (58 ± 29 days) after stroke. We used the Rivermead Motor Assessment score and a newly developed scale for qualitative gait parameters and we demonstrate that two times 30 minutes physiotherapy (PT) daily followed by 30 minutes treadmill training (LB) plus 30 minutes physiotherapy (PT-LB) daily was significantly more effective than the reverse order (LB- PT). By the end of the study 75% of the PT-LB patients were ambulatory, while only 36% of the LB-PT were able to walk. We hypothesize that the observed difference is due to an improvement of postural stability by intensive physiotherapy in the first phase which leads to a significant improvement of the quantitative and the qualitative gait parameters during treadmill training.
... Mixed approaches [15][16][17] 3 (127) Motor approaches 20 1 (91) Neurophysiological approaches 17 1 (15) Biofeedback (force) [33][34][35][36] 4 (161) Moving platform 135,136 2 (40) Repetitive task training 20,143,144 3 (132) Gait (walking speed) Mixed approaches 15,16,18,19 4 (350) Motor approaches [20][21][22] 3 (117) Neurophysiological approaches 17,27 2 (113) Biofeedback (force) 39 1 (41) Biofeedback (position) [40][41][42][43][44] 5 (165) EMG biofeedback [75][76][77] 3 (36) Electromechanical-assisted gait training 82 16,17,22,117,[119][120][121][122] 8 (332) Fitness (strength) [116][117][118] 3 (110) High-intensity therapy [17][18][19]124,128,129 6 (524) Repetitive task training [20][21][22]27,124 5 (263) Rhythmic gait cueing 43,147,148 3 (121) Treadmill 88,114,115,[176][177][178][179][180] Figure 3: Interventions to improve balance, gait, or mobility after stroke The fi gure summarises the results for lower-limb interventions targeting the recovery of sit-to-stand ability, standing balance, and gait, and shows the intervention category, number of trials (participants recruited) plus the SMD and 95% CI for the eff ect of the intervention on the outcome measure. Sit-to-stand ability was measured using assessments such as the timed up-and-go test. ...
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.
Background
Treadmill training, with or without body weight support using a harness, is used in rehabilitation and might help to improve walking
after stroke. This is an update of the Cochrane review first published in 2003 and updated in 2005 and 2014.
Objectives
To determine if treadmill training and body weight support, individually or in combination, improve walking ability, quality of life,
activities of daily living, dependency or death, and institutionalisation or death, compared with other physiotherapy gait-training
interventions after stroke. The secondary objective was to determine the safety and acceptability of this method of gait training.
Search methods
We searched the Cochrane Stroke Group Trials Register (last searched 14 February 2017), the Cochrane Central Register of Controlled
Trials (CENTRAL) and the Database of Reviews of Effects (DARE) (the Cochrane Library 2017, Issue 2), MEDLINE (1966 to 14
February 2017), Embase (1980 to 14 February 2017), CINAHL (1982 to 14 February 2017), AMED (1985 to 14 February 2017) and
SPORTDiscus (1949 to 14 February 2017). We also handsearched relevant conference proceedings and ongoing trials and research
registers, screened reference lists, and contacted trialists to identify further trials.
Selection criteria
Randomised or quasi-randomised controlled and cross-over trials of treadmill training and body weight support, individually or in
combination, for the treatment of walking after stroke.
Data collection and analysis
Two review authors independently selected trials, extracted data, and assessed risk of bias and methodological quality. The primary
outcomes investigated were walking speed, endurance, and dependency.
Main results
We included 56 trials with 3105 participants in this updated review. The average age of the participants was 60 years, and the studies
were carried out in both inpatient and outpatient settings. All participants had at least some walking difficulties and many could not walk
without assistance. Overall, the use of treadmill training did not increase the chances of walking independently compared with other
physiotherapy interventions (risk difference (RD) -0.00, 95% confidence interval (CI) -0.02 to 0.02; 18 trials, 1210 participants; P =
0.94; I2 = 0%; low-quality evidence). Overall, the use of treadmill training in walking rehabilitation for people after stroke increased the
walking velocity and walking endurance significantly. The pooled mean difference (MD) (random-effects model) for walking velocity
was 0.06 m/s (95% CI 0.03 to 0.09; 47 trials, 2323 participants; P < 0.0001; I2 = 44%; moderate-quality evidence) and the pooled
MD for walking endurance was 14.19 metres (95% CI 2.92 to 25.46; 28 trials, 1680 participants; P = 0.01; I2 = 27%; moderate-
quality evidence). Overall, the use of treadmill training with body weight support in walking rehabilitation for people after stroke did
not increase the walking velocity and walking endurance at the end of scheduled follow-up. The pooled MD (random-effects model)
for walking velocity was 0.03 m/s (95% CI -0.05 to 0.10; 12 trials, 954 participants; P = 0.50; I2 = 55%; low-quality evidence) and
the pooled MD for walking endurance was 21.64 metres (95% CI -4.70 to 47.98; 10 trials, 882 participants; P = 0.11; I2 = 47%; low-
quality evidence). In 38 studies with a total of 1571 participants who were independent in walking at study onset, the use of treadmill
training increased the walking velocity significantly. The pooled MD (random-effects model) for walking velocity was 0.08 m/s (95%
CI 0.05 to 0.12; P < 0.00001; I 2 = 49%). There were insufficient data to comment on any effects on quality of life or activities of daily
living. Adverse events and dropouts did not occur more frequently in people receiving treadmill training and these were not judged to
be clinically serious events.
Authors’ conclusions
Overall, people after stroke who receive treadmill training, with or without body weight support, are not more likely to improve
their ability to walk independently compared with people after stroke not receiving treadmill training, but walking speed and walking
endurance may improve slightly in the short term. Specifically, people with stroke who are able to walk (but not people who are
dependent in walking at start of treatment) appear to benefit most from this type of intervention with regard to walking speed and
walking endurance. This review did not find, however, that improvements in walking speed and endurance may have persisting beneficial
effects. Further research should specifically investigate the effects of different frequencies, durations, or intensities (in terms of speed
increments and inclination) of treadmill training, as well as the use of handrails, in ambulatory participants, but not in dependent
walkers.
Treadmill training with body weight support was examined in 58 patients with acquired brain damages with the aim of improving gait ability. Furthermore it was proved whether the effectiveness of treadmill training could be increased by introducing choice criteria. The first group of patients (unspecific group, n = 25) was chosen for the treadmill training by random principle. The following choice criteria were taken into consideration for the second group of patients (specific group, n = 33) as an access condition for the treadmill training: gait inability (Functional Ambulation Categories value 0 to 2); motoric conditions (free sitting; palpable muscle function of the hip extensors, hip abductors, knee extensors in the concerned leg); sufficient cooperation, motivation and vigilance; a treatment durance of at least four weeks, lack of gait-relevant contractures as well as starting treadmill training not later than one year after the disease event took place. Parallel to treadmill training both patient groups received a conventional physiotherapy to the same extent. Durance of treadmill training amounted nine weeks in both groups. Mean age of patients of the second group (59 years) was about 12 years higher than that of the first group (47 years on average). Gait ability, which was evaluated by the Functional Ambulation Categories Scale, improved in direct comparison from 68% within the first group to 82% within the second group. The independent gait ability without helping tools increased from 20% to 45%. In the second group the same number of patients of age group 70 - 82 achieved improvement of gait ability as patients of age group 30 - 49 did. Our results show that patients with acquired brain damages profit from treadmill training and that the given choice criteria enable a further improvement of result.
Treadmill training, with or without body weight support using a harness, is used in rehabilitation and might help to improve walking after stroke. This is an update of a Cochrane review first published in 2005.
To determine if treadmill training and body weight support, individually or in combination, improve walking ability, quality of life, activities of daily living, dependency or death, and institutionalisation or death, compared with other physiotherapy gait training interventions after stroke. The secondary objective was to determine the safety and acceptability of this method of gait training.
We searched the Cochrane Stroke Group Trials Register (last searched June 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Reviews of Effects (DARE) (The Cochrane Library 2013, Issue 7), MEDLINE (1966 to July 2013), EMBASE (1980 to July 2013), CINAHL (1982 to June 2013), AMED (1985 to July 2013) and SPORTDiscus (1949 to June 2013). We also handsearched relevant conference proceedings and ongoing trials and research registers, screened reference lists and contacted trialists to identify further trials.
Randomised or quasi-randomised controlled and cross-over trials of treadmill training and body weight support, individually or in combination, for the treatment of walking after stroke.
Two authors independently selected trials, extracted data and assessed methodological quality. The primary outcomes investigated were walking speed, endurance and dependency.
We included 44 trials with 2658 participants in this updated review. Overall, the use of treadmill training with body weight support did not increase the chances of walking independently compared with other physiotherapy interventions (risk difference (RD) -0.00, 95% confidence interval (CI) -0.02 to 0.02; P = 0.94; I² = 0%). Overall, the use of treadmill training with body weight support in walking rehabilitation for patients after stroke increased the walking velocity and walking endurance significantly. The pooled mean difference (MD) (random-effects model) for walking velocity was 0.07 m/s (95% CI 0.01 to 0.12; P = 0.02; I² = 57%) and the pooled MD for walking endurance was 26.35 metres (95% CI 2.51 to 50.19; P = 0.03; I² = 60%). Overall, the use of treadmill training with body weight support in walking rehabilitation for patients after stroke did not increase the walking velocity and walking endurance at the end of scheduled follow-up significantly. The pooled MD (random-effects model) for walking velocity was 0.04 m/s (95% CI -0.06 to 0.14; P = 0.40; I² = 40%) and the pooled MD for walking endurance was 32.36 metres (95% CI -3.10 to 67.81; P = 0.07; I² = 63%). However, for ambulatory patients improvements in walking endurance lasted until the end of scheduled follow-up (MD 58.88 metres, 95% CI 29.10 to 88.66; P = 0.0001; I² = 0%). Adverse events and drop outs did not occur more frequently in people receiving treadmill training and these were not judged to be clinically serious events.
Overall, people after stroke who receive treadmill training with or without body weight support are not more likely to improve their ability to walk independently compared with people after stroke not receiving treadmill training, but walking speed and walking endurance may improve. Specifically, stroke patients who are able to walk (but not people who are not able to walk) appear to benefit most from this type of intervention. This review found that improvements in walking endurance in people able to walk may have persisting beneficial effects. Further research should specifically investigate the effects of different frequencies, durations or intensities (in terms of speed increments and inclination) of treadmill training, as well as the use of handrails, in ambulatory patients, but not in dependent walkers.
Die Laufbandtherapie (LBT) mit Körpergewichtsentlastung wurde an 30 Patienten mit ischämischem Hirninfarkt mit dem Ziel der Verbesserung der Gehfähigkeit und der daraus resultierenden Unabhängigkeit in den Aktivitäten des täglichen Lebens (ADL) durchgeführt. Folgende Auswahlkriterien wurden dabei zugrunde gelegt: Gehunfähigkeit (FAC-Wert 0 - 2); motorische Voraussetzungen (freier Sitz, palpierbare Muskelfunktion der Hüftgelenkextensoren, -abduktoren, Knieextensoren im betroffenem Bein); ausreichende Kooperation, Motivation und Vigilanz; Fehlen gangrelevanter Kontrakturen sowie Beginn der LBT nicht später als ein Jahr nach dem Krankheitsereignis. Die Dauer der LBT betrug im Durchschnitt 6,6 Wochen. Das Durchschnittsalter der Patienten lag bei 68 (46 - 82) Jahren. 87 % der Patienten konnten ihre Gehfähigkeit innerhalb der Functional Ambulation Categories (FAC) Scale verbessern. Die selbstständige Gehfähigkeit ohne Hilfsmittel (FAC-Wert 3 - 5) erreichten 60 % der Patienten. Neben der Verbesserung der Gehfähigkeit erzielten die Patienten auch in der motorischen Skala Rivermead Motor Assessment (gross function) und den motorischen Anteilen der ADL-Skalen Barthel-Index (Items 2 - 4) und Functional Independence Measure (Items 3 und 4) signifikante Verbesserungen. Die Laufbandtherapie etabliert sich zu einem wichtigen Therapieansatz der Gangrehabilitation von Patienten mit erworbenen Hirnschäden.
Fragestellung: Behandlungen mit speziellem Laufbandtraining konnten in der Rehabilitation neurologisch bedingter Gangstörungen in den letzten 10 Jahren bemerkenswerte Erfolge erzielen. Es sollte untersucht werden, ob und wie sich Laufbandtherapie (LT) und Vojta-Therapie (VT) wechselseitig ergänzen. Methodik: In einer Pilotstudie erhielten 21 MS-Patienten täglich eine Behandlung mit der Abfolge LT - VT - LT. Am 2., 12. und 22. Behandlungstag änderte sich der Therapieablauf: zuerst VT und danach zwei Einheiten LT. Am 1., 2., 11., 12., 21. und 22. Behandlungstag wurde nach jedem Therapieabschnitt das Gehverhalten untersucht. Außerdem erfolgte mittels Haut-EMG eine Registrierung der elektromyographischen Aktivitäten während der VT. Die neurologische Begutachtung bestand aus skalierten Einschätzungen des Behinderungsgrades (EDSS nach Kurtzke), der Zerebellarfunktionen, der Spastik und der Muskelkraft vor der ersten und letzten Therapie. Zur Erhöhung der Empfindlichkeit wurden die zugrunde liegenden definierten Skalierungsabstufungen halbiert. Ergebnisse: Die Untersuchungen zeigen, dass die elektromyographischen Aktivitäten in der VT weit überwiegend größer ausfallen, wenn vorher LT stattgefunden hat. Die in der zweiten LT zurückgelegten Gehstrecken sind signifikant länger als die in der gleich langen ersten LT-Einheit bei der Therapieabfolge LT - VT - LT. Gehgeschwindigkeit und Schrittlänge werden signifikant (p < 0,0001) verbessert. 16 von 19 neurologisch untersuchten Patienten verbesserten sich in der EDSS um 0,25 - 1 Stufe. Außerdem werden die Zerebellarfunktionen (bei 68,4 %) und die Muskelkräfte am stärker betroffenen Bein (bei 78,9 %) auffallend verbessert. Schlussfolgerung: Im Gegensatz zu einer zwei Jahre zuvor untersuchten vergleichbaren Patientengruppe, die wöchentlich mit gleicher Zeitsumme aus VT und LT, aber anderer Zeitabfolge behandelt worden war, erhält man bei Gehgeschwindigkeit, Behinderungsgrad und Kleinhirnsymptomatik bemerkenswert größere Erfolge. Daher wird vermutet, dass die Abfolge LT - VT - LT mehr bewirkt als nur die Summe der einzelnen Therapiezeiten.
Functional electrical stimulation (FES) is a suitable method for the therapy of hemiparetic walking. However, FES requires suitable human and muscle models in order to achieve fast improvements of the patient's gait. Furthermore, an intelligent control scheme is to be employed considering the patient's autonomous motor activity. This paper presents the general therapeutic approach to therapy the hemiparetic gait. Further, human body and muscle models are presented and control algorithm are proposed. Concluding results from simulations and experiments are presented and debated.
SummaryBackground Treadmill retraining of gait has been proposed as a useful adjunct to conventional physical therapy to restore ability to walk after stroke.Aim To inform clinical practice by evaluating the research evidence for the effectiveness of treadmill retraining of gait after stroke.Design A systematic review.Search strategy An electronic search of Medline, Embase, Cinahl, Amed and PEDro combined with a hand search of papers published in relevant peer-reviewed journals.Inclusion criteria for and identification of studies Published, human, English language, controlled studies investigating treadmill retraining of gait for adults with a diagnosis of stroke and hemiplegia. The two authors independently examined the abstracts of studies highlighted to identify those which met the inclusion criteria.Data collection and analysis Studies which met the inclusion criteria were reviewed by both authors independently and classified into categories: treadmill versus no treatment, treadmill plus partial bodyweight support (PBWS) versus no treatment, treadmill plus PBWS versus treadmill, treadmill versus physical therapy and treadmill plus PBWS versus physical therapy. Each author independently extracted relevant data on the subjects, study design, interventions, outcome measures and results. Any disagreements were resolved through discussion.Findings Twelve studies fulfilled the inclusion criteria – five single case studies and seven randomised controlled trials. The review suggests that although treadmill retraining of gait, especially with PBWS, might improve gait parameters and functional mobility, unless treadmill retraining is directed at improving gait speed it might be no more effective than conventional physical therapy at improving gait parameters.Limitations The findings of this review are limited by a lack of comprehensive investigation of conventional physical therapy interventions, difficulty comparing primary studies which investigated subjects at different time points after stroke using a variety of outcome measures, and the quality of the included primary studies.Implications for clinical practice This review suggests that there is little evidence as yet to justify changing clinical practice in favour of treadmill retraining of gait after stroke.
Physical activity (PA) has potential benefits after stroke or spinal cord injury (SCI), especially in improving efficiency and functional capacity in activities of daily living. Currently, many who could benefit from PA may be routinely excluded from participation because of myths related to functional capacity and the concern for harm. The purpose of this review was to evaluate the literature for reports of adverse events during exercise after stroke or SCI, and to provide recommendations regarding exercise participation in supervised and unsupervised environments. Studies were evaluated for quality, and the summary level and quality of evidence were evaluated using the AGREE rubric, modified to address the main outcome measure of adverse events. Levels of exercise stress were evaluated for aerobic activities, using an established rubric. Included in the current analysis were 32 studies for stroke and 4 for SCI. In aggregate, this yielded a total of 730 experimental participants with stroke and 143 with SCI. It should be noted that almost all studies were not designed to examine naturally occurring adverse events from PA. Significant contraindications to unsupervised exercise include manifestation of autonomic dysreflexia in SCI and cardiovascular comorbidity after stroke. There are clear benefits of exercise training on physiological outcomes in stroke and SCI, but the relation between outcomes and safety remains unclear. However, taken on balance, the risk-to-benefit ratio favors the recommendation of exercise. This recommendation is based on studies in which participants were almost universally screened for participation in supervised environments. Thus, the grading of evidence for finding adverse events to support this conclusion is inadequate.
Does mechanically assisted walking with body weight support result in more independent walking and is it detrimental to walking speed or capacity in non-ambulatory patients early after stroke?
Systematic review with meta-analysis of randomised trials.
Non-ambulatory adult patients undergoing inpatient rehabilitation up to 3 months after stroke.
Mechanically assisted walking (eg, treadmill, electromechanical gait trainer, robotic device, servo-motor) with body weight support (eg, harness with or without handrail, but not handrail alone) versus assisted overground walking of longer than 15 min duration.
The primary outcome was the proportion of participants achieving independent walking. Secondary outcomes were walking speed measured as m/s during the 10-m Walk Test and walking capacity measured as distance in m during the 6-min Walk Test.
Six studies comprising 549 participants were identified and included in meta-analyses. Mechanically assisted walking with body weight support resulted in more people walking independently at 4 weeks (RD 0.23, 95% CI 0.15 to 0.30) and at 6 months (RD 0.23, 95% CI 0.07 to 0.39), faster walking at 6 months (MD 0.12 m/s, 95% CI 0.02 to 0.21), and further walking at 6 months (MD 55 m, 95% CI 15 to 96) than assisted overground walking.
Mechanically assisted walking with body weight support is more effective than overground walking at increasing independent walking in non-ambulatory patients early after stroke. Furthermore, it is not detrimental to walking speed or capacity and clinicians should therefore be confident about implementing this intervention.
Is treadmill walking with body weight support during inpatient rehabilitation detrimental to walking quality compared with assisted overground walking? Does it result in better walking capacity, perception of walking or community participation?
Analysis of secondary outcomes of a randomised trial with concealed allocation, assessor blinding and intention-to-treat analysis.
126 patients unable to walk within 4 weeks of a stroke who were undergoing inpatient rehabilitation.
The experimental group undertook up to 30 minutes of treadmill walking with body weight support via an overhead harness per day while the control group undertook up to 30 minutes of overground walking.
The secondary outcomes were walking quality and capacity, walking perception, community participation and falls.
Six months after entering the study, there was no difference between the groups of independent walkers in terms of speed (MD 0.10 m/s, 95% CI -0.06 to 0.26) or stride (MD 6 cm, 95% CI -7 to 19). The independent walkers in the experimental group walked 57 m further (95% CI 1 to 113) in the 6 min walk than those in the control group. The experimental group (walkers and non-walkers) rated their walking 1 point out of 10 (95% CI 0.1 to 1.9) higher than the control group. There was no difference between the groups in community participation or number of falls.
Treadmill training with body weight support results in better walking capacity and perception of walking compared to overground walking without deleterious effects on walking quality.
The main objective of this randomized trial was to determine whether treadmill walking with body weight support was effective at establishing independent walking more often and earlier than current physiotherapy intervention for nonambulatory stroke patients.
A randomized trial with concealed allocation, blinded assessment, and intention-to-treat analysis was conducted. One hundred twenty-six stroke patients who were unable to walk were recruited and randomly allocated to an experimental or a control group within 4 weeks of stroke. The experimental group undertook up to 30 minutes per day of treadmill walking with body weight support via an overhead harness whereas the control group undertook up to 30 minutes of overground walking. The primary outcome was the proportion of participants achieving independent walking within 6 months.
Kaplan-Meier estimates of the proportion of experimental participants who achieved independent walking were 37% compared with 26% of the control group at 1 month, 66% compared with 55% at 2 months, and 71% compared with 60% at 6 months (P=0.13). The experimental group walked 2 weeks earlier, with a median time to independent walking of 5 weeks compared to 7 weeks for the control group. In addition, 14% (95% CI, -1-28) more of the experimental group were discharged home.
Treadmill walking with body weight support is feasible, safe, and tends to result in more people walking independently and earlier after stroke. Trial Registration- ClinicalTrial.gov (NCT00167531).
This thesis is based on the findings of the FuPro-Stroke study (the Stroke section of the Functional Prognostification and disability study on neurological disorders), which is a multicentre, prospective cohort study among patients with stroke, who were included during inpatient rehabilitation. The aim of the research reported on in the present thesis was to investigate the long-term prognosis of chronic stroke outcome up to 3 years after onset. Poor mobility status is a key concern in chronic stroke patients, especially since it may lead to ADL dependence and affect social reintegration. We found that mobility at one-year post stroke could be predicted by functional status, sitting balance, time between stroke onset and measurement, and age. We also investigated determinants that could predict decline in mobility status in chronic stroke patients. Inactivity in terms of instrumental activities of daily living (IADL), cognitive problems, fatigue and depressive symptoms at one year post stroke were the main predictors for deterioration in mobility. Community ambulation is an important outcome for stroke patients and we found that this variable was closely related to gait speed. The optimal cut-off point for community ambulation was 0.66 m/s. Balance, endurance and the use of an assistive walking device were determinants that confounded the relation between community ambulation and gait speed. The effectiveness of training programmes focusing on lower limb strengthening, cardio-respiratory fitness or gait-oriented tasks, in terms of the outcome of gait, gait-related activities and health-related quality of life (HRQoL) after stroke were also investigated. Twenty-one high quality RCTs were included, five of which focused on lower limb strengthening, two on cardio-respiratory fitness training and 14 on gait-oriented training. After conducting a meta-analysis we suggested that gait-oriented training is the most successful method to improve walking competency after stroke. Depression and fatigue are both well-known sequels after stroke. At three years post stroke, 19% of the patients showed depressive symptoms. Depression was best predicted by one-year IADL activity and fatigue. It was also shown that 68%, 74% and 58% of the patients experienced fatigue at 6, 12 and 36 months post stroke, respectively. Fatigue was significantly related to IADL and HRQoL, but not to ADL. Depression and motor impairment were important confounders in the relationship between fatigue and IADL and HRQoL. Since the number of stroke patients is rising and it is a chronic disease, it is important that appropriate care is provided to suit the needs of all these patients. We suggest in our study that 33% of the patients perceived at least one unmet care demand at three years after stroke. Younger age, motor impairment, fatigue and depressive symptoms were significantly related to the presence of unmet demands. These results suggest that our health care system is as yet not fully meeting the demands of patients with chronic stroke. Our advise is that the focus of care and research should be on improving our understanding of the course of functional recovery by monitoring patients over time, introducing innovative intervention strategies and exploring the underlying mechanisms of functional improvement after stroke.
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 bestresearch 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% CI 0.03–0.23) for effects of high intensity of exercise training to 0.92 (95% CI 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% CI 0.07–0.91), treadmill training with or without body weight support, respectively 0.70 (95% CI 0.29–1.10) and 1.09 (95% CI 0.56–1.61), aerobics (SES 0.39; 95% CI 0.05–0.74), external auditory rhythms during gait (SES 0.91; 95% CI 0.40–1.42) and neuromuscular stimulation for glenohumeral subluxation (SES 1.41; 95% CI 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.
Background:
Treadmill training, with some body weight supported using a harness, is a method of treating walking after stroke. Systematic review is required to assess the cost, effectiveness and acceptance of this treatment.
Objectives:
To assess the effectiveness of treadmill training and/or body weight support in the treatment of walking after stroke. The primary outcomes investigated were walking speed and walking dependency.
Search strategy:
We searched the Cochrane Stroke Group Trials Register (last searched 21 March 2003), the Cochrane Central Register of Controlled Trials (Cochrane Library, Issue 1 2003), MEDLINE (1966-March 2003), EMBASE (1980-March 2003), CINAHL (1982-February 2003) and PEDro (last searched 21 March 2003). In addition, we handsearched relevant conference proceedings, screened reference lists and contacted trialists to identify further published and unpublished trials.
Selection criteria:
Randomised, or quasi-randomised, controlled and cross-over trials of treadmill training and/or body weight support for the treatment of walking after stroke were eligible.
Data collection and analysis:
Two reviewers independently selected trials and extracted data. Trialists were contacted for additional information. A fixed effects model was used for analysis, but if heterogeneity existed (Chi squared statistic) a random effects model was used. Results were analysed as weighted mean differences (WMD) for continuous variables and relative risk (RR) for dichotomous variables. The main outcome variables were walking speed and dependency.
Main results:
Eleven trials (458 participants) were included. There were no statistically significant differences between treadmill training, with or without body weight support, and other interventions for walking speed or dependence. There was a small trend toward the effectiveness of treadmill training with body weight support for participants who could walk independently (WMD: 0.24 m/sec, 95% CI: -0.19 to 0.66 for speed; random effects). The one trial which compared treadmill training with and without body weight support showed benefit at the end of follow-up (mean difference: 0.22 m/sec, 95% CI: 0.05 to 0.39). Adverse events occurred slightly more frequently in participants receiving treadmill training, although statistically there were no differences.
Reviewer's conclusions:
Overall, no statistically significant effect of treadmill training and body weight support was detected. However, among people who could walk independently, treadmill training with body weight support appeared to be more effective than other interventions at improving walking speed, but this conclusion was not robust.
To determine the longitudinal association of poststroke fatigue with activities of daily living (ADL), instrumental ADL (IADL) and perceived health-related quality of life (HRQoL) and to establish whether this relationship is confounded by other determinants.
A prospective cohort study of stroke patients consecutively admitted for inpatient rehabilitation was conducted. ADL, IADL and HRQoL were assessed in 223 patients at 6, 12 and 36 months after stroke. Fatigue was determined by the Fatigue Severity Scale. Random coefficient analysis was used to analyze the impact of fatigue on ADL, IADL and HRQoL. The association between fatigue and outcome was corrected for potential confounders, i.e. age, gender, comorbidity, executive function, severity of paresis and depression. The covariate was considered to be a confounder if the regression coefficient of fatigue on outcome changed by >15%.
Fatigue was significantly related to IADL and HRQoL but not to ADL. The relation between fatigue and IADL was confounded by depression and motor impairment. Depression biased the relation between fatigue and HRQoL, but fatigue remained independently related to HRQoL.
Fatigue is longitudinally spuriously associated with IADL and independently with HRQoL. These findings suggest that in examining the impact of poststroke fatigue on outcome, one should control for confounders such as depression.
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.
The aim of the study was to identify factors that are significantly related to depression in chronic stroke patients.
Prospective cohort study of stroke patients admitted for rehabilitation. A total of 165 first ever stroke patients over 18 years of age were assessed at one and three years post stroke. Depression was determined by the Centre for Epidemiologic Studies Depression Scale (CES-D). Patients with scores >/=16 were classified as depressed. Bivariate and multivariate logistic regression analyses were used to identify prognostic factors for depression.
At three years post stroke, 19% of the patients were depressed. Bivariate analysis showed significant associations between post-stroke depression and type of stroke, fatigue, motor function of the leg and arm, activities of daily living (ADL) independency and instrumental ADL. Multivariate logistic regression analysis showed that depression was predicted by one-year instrumental ADL and fatigue. Sensitivity of the model was 63%, while specificity was 85%.
The present prospective cohort study showed that depression three years after stroke can be predicted by instrumental ADL and fatigue one year post stroke. Recognition of prognostic factors in patients at risk may help clinicians to apply interventions aimed at preventing depression in chronic stroke.
To explore the strength of the association between gait speed and community ambulation and whether this association is significantly distorted by other variables.
Cross-sectional study conducted 3 years after stroke.
A total of 102 patients after first-ever stroke following inpatient rehabilitation who are now living in the community.
Community ambulation was determined by a self-administered questionnaire with 4 categories. Gait speed was assessed by the 5-m walking test. Possible confounding factors included in the analyses were: age, hemisphere, living alone, history of falls, use of assistive walking devices, executive function (Trail Making Test), depression (Center for Epidemiologic Studies-Depression scale), fatigue (Fatigue Severity Scale), motor function (Motricity Index), standing balance (Berg Balance Scale) and walking endurance (SF36).
Twenty-six percent of the patients were non-community walkers or limited community walkers. The optimal cut-off point for community ambulation was 0.66 m/sec, with an area under the curve of 0.85. Although gait speed was significantly related to community ambulation, this association was confounded by balance, motor function, endurance and the use of an assistive walking device. These factors reduced the regression coefficient of gait speed by more than 15%.
Gait speed is an important factor related to community walking; however, ability to walk in the community is determined by several underlying factors, e.g. balance, motor function, endurance and assistive walking device.
To determine whether repetitive functional task practice (RFTP) after stroke improves limb-specific or global function or activities of daily living and whether treatment effects are dependent on the amount of practice, or the type or timing of the intervention. Also to provide estimates of the cost-effectiveness of RFTP.
The main electronic databases were searched from inception to week 4, September 2006. Searches were also carried out on non-English-language databases and for unpublished trials up to May 2006.
Standard quantitative methods were used to conduct the systematic review. The measures of efficacy of RFTP from the data synthesis were used to inform an economic model. The model used a pre-existing data set and tested the potential impact of RFTP on cost. An incremental cost per quality-adjusted life-year (QALY) gained for RFTP was estimated from the model. Sensitivity analyses around the assumptions made for the model were used to test the robustness of the estimates.
Thirty-one trials with 34 intervention-control pairs and 1078 participants were included. Overall, it was found that some forms of RFTP resulted in improvement in global function, and in both arm and lower limb function. Overall standardised mean difference in data suitable for pooling was 0.38 [95% confidence interval (CI) 0.09 to 0.68] for global motor function, 0.24 (95% CI 0.06 to 0.42) for arm function and 0.28 (95% CI 0.05 to 0.51) for functional ambulation. Results suggest that training may be sufficient to have an impact on activities of daily living. Retention effects of training persist for up to 6 months, but whether they persist beyond this is unclear. There was little or no evidence that treatment effects overall were modified by time since stroke or dosage of task practice, but results for upper limb function were modified by type of intervention. The economic modelling suggested that RFTP was cost-effective. Given a threshold for cost-effectiveness of 20,000 pounds per QALY gained, RFTP is cost-effective so long as the net cost per patient is less than 1963 pounds. This result showed some sensitivity to the assumptions made for the model. The cost-effectiveness of RFTP tends to stem from the relatively modest cost associated with this intervention.
The evidence suggests that some form of RFTP can be effective in improving lower limb function at any time after stroke, but that the duration of intervention effect is unclear. There is as yet insufficient good-quality evidence to make any firm recommendations for upper limb interventions. If task-specific training is used, adverse effects should be monitored. While the effectiveness of RFTP is relatively modest, this sort of intervention appears to be cost-effective. Owing to the large number of ongoing trials, this review should be updated within 2 years and any future review should include a comparison against alternative treatments. Further research should evaluate RFTP upper limb interventions and in particular constraint-induced movement therapy, address practical ways of delivering RFTP interventions, be directed towards the evaluation of suitable methods to maintain functional gain, and be powered to detect whether RFTP interventions are cost-effective.
ResearchGate has not been able to resolve any references for this publication.