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Sun Y, Zhang S, Zhao T, Sun C, Li P, Zhang L. Effectiveness of Telehealth-Based Exercise Interventions for Patients With Stroke: A Meta-Analysis of Randomised Controlled Trials. J Clin Nurs 2025. [PMID: 40275623 DOI: 10.1111/jocn.17792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 01/31/2025] [Accepted: 04/14/2025] [Indexed: 04/26/2025]
Abstract
AIM To explore the effects of telehealth-based exercise interventions on balance, motor function, walking ability and activities of daily living (ADLs) in patients with stroke. DESIGN Meta-analysis of randomised controlled trials. METHODS This meta-analysis of randomised controlled trials was reported to follow the PRISMA statement and the Cochrane Handbook guidelines. The study employed either a fixed-effects model or a random-effects model according to the statistical heterogeneity observed. DATA SOURCES The literature search was performed in six databases including PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, PsycINFO and CINAHL from inception to December 2023. RESULTS A total of 15 randomised controlled trials were included in this meta-analysis. Most of the studies were evaluated for some concerns. The quality of the evidence in this analysis ranged from low to moderate in terms of the outcome. Meta-analysis revealed that telehealth-based exercise interventions presented significant effects on walking ability, motor function and ADLs in patients with stroke. Nonetheless, the balance remained unaffected by statistical significance. CONCLUSION Telehealth-based exercise interventions could effectively improve walking ability, motor function and ADLs in patients with stroke; however, the impact on balance was not significant. Telehealth-based exercise interventions are recommended for stroke survivors residing in remote areas or facing economic constraints. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE This meta-analysis showed that telehealth-based exercise interventions could bring benefits to the rehabilitation of patients with stroke. Telehealth-based exercise interventions should be considered effective to better promote the rehabilitation of patients. REPORTING METHOD The study was reported in compliance with the PRISMA statement. PATIENT OR PUBLIC CONTRIBUTION None. TRIAL REGISTRATION PROSPERO (https://www.crd.york.ac.uk/PROSPERO): CRD42024501015.
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Affiliation(s)
- Yize Sun
- Department of Nursing, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, P.R. China
| | - Saiya Zhang
- Department of Nursing, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, P.R. China
| | - Tianrui Zhao
- Department of Nursing, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, P.R. China
| | - Chenglin Sun
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, P.R. China
| | - Ping Li
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, P.R. China
| | - Lihua Zhang
- Department of Nursing, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, P.R. China
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Wang J, Li X, Yang F, Guo P, Ren C, Duan Z, Bi M, Kong Y, Zhang Y. Investigating the impact of multicomponent training for improving lower limb dysfunction in people with stroke: A scoping review of randomized clinical trials. Geriatr Nurs 2025; 62:41-50. [PMID: 39914228 DOI: 10.1016/j.gerinurse.2025.01.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 11/14/2024] [Accepted: 01/23/2025] [Indexed: 04/08/2025]
Abstract
Multicomponent training (MCT) is characterized by the combination of at least 3 types of training, and may be a promising intervention strategy for stroke. This study conducted a scoping review of randomized clinical trials (RCTs) to analyze the available evidence of MCT on improving lower limb dysfunction in stroke patients. Systematic searches were conducted in eight electronic databases. A total of 14 eligible RCTs from 8 countries were included. Among the included studies, MCT mainly combines aerobic, resistance, balance, and stretching exercises. The intensity, frequency, and duration of exercise interventions varied significantly across studies. The findings of most studies indicated that MCT significantly improved lower limb functional outcomes in stroke patients, including walking speed, 6-min Walk Test scores, and Berg Balance Scale scores. However, due to limited evidence, further research is needed to draw more definitive conclusions about the benefits of MCT strategy on lower limb dysfunction in stroke patients.
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Affiliation(s)
- Jing Wang
- Rehabilitation Medicine College, Henan University of Chinese Medicine, 156 Jinshui East Road, Zhengzhou, Henan, China
| | - Xinmin Li
- School of Traditional Chinese Medicine, Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Fangjie Yang
- Rehabilitation Medicine College, Henan University of Chinese Medicine, 156 Jinshui East Road, Zhengzhou, Henan, China
| | - Pengxue Guo
- Rehabilitation Medicine College, Henan University of Chinese Medicine, 156 Jinshui East Road, Zhengzhou, Henan, China
| | - Chunlin Ren
- Rehabilitation Medicine College, Henan University of Chinese Medicine, 156 Jinshui East Road, Zhengzhou, Henan, China
| | - Zhengfei Duan
- Rehabilitation Medicine College, Henan University of Chinese Medicine, 156 Jinshui East Road, Zhengzhou, Henan, China
| | - Mengyao Bi
- Rehabilitation Medicine College, Henan University of Chinese Medicine, 156 Jinshui East Road, Zhengzhou, Henan, China
| | - Yuting Kong
- Rehabilitation Medicine College, Henan University of Chinese Medicine, 156 Jinshui East Road, Zhengzhou, Henan, China
| | - Yasu Zhang
- Rehabilitation Medicine College, Henan University of Chinese Medicine, 156 Jinshui East Road, Zhengzhou, Henan, China.
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Todhunter-Brown A, Sellers CE, Baer GD, Choo PL, Cowie J, Cheyne JD, Langhorne P, Brown J, Morris J, Campbell P. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database Syst Rev 2025; 2:CD001920. [PMID: 39932103 PMCID: PMC11812092 DOI: 10.1002/14651858.cd001920.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2025]
Abstract
BACKGROUND Various approaches to physical rehabilitation to improve function and mobility are used after stroke. There is considerable controversy around the relative effectiveness of approaches, and little known about optimal delivery and dose. Some physiotherapists base their treatments on a single approach; others use components from several different approaches. OBJECTIVES Primary objective: To determine whether physical rehabilitation is effective for recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach. SECONDARY OBJECTIVE To explore factors that may impact the effectiveness of physical rehabilitation approaches, including time after stroke, geographical location of study, intervention dose/duration, intervention provider, and treatment components. Stakeholder involvement: Key aims were to clarify the focus of the review, inform decisions about subgroup analyses, and co-produce statements relating to key implications. SEARCH METHODS For this update, we searched the Cochrane Stroke Trials Register (last searched November 2022), CENTRAL (2022, Issue 10), MEDLINE (1966 to November 2022), Embase (1980 to November 2022), AMED (1985 to November 2022), CINAHL (1982 to November 2022), and the Chinese Biomedical Literature Database (to November 2022). SELECTION CRITERIA Inclusion criteria: Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. EXCLUSION CRITERIA RCTs of upper limb function or single treatment components. PRIMARY OUTCOMES measures of independence in activities of daily living (IADL) and motor function. SECONDARY OUTCOMES balance, gait velocity, and length of stay. DATA COLLECTION AND ANALYSIS Two independent authors selected studies according to pre-defined eligibility criteria, extracted data, and assessed the risk of bias in the included studies. We used GRADE to assess the certainty of evidence. MAIN RESULTS In this review update, we included 267 studies (21,838 participants). Studies were conducted in 36 countries, with half (133/267) in China. Generally, studies were heterogeneous, and often poorly reported. We judged only 14 studies in meta-analyses as at low risk of bias for all domains and, on average, we considered 33% of studies in analyses of primary outcomes at high risk of bias. Is physical rehabilitation more effective than no (or minimal) physical rehabilitation? Compared to no physical rehabilitation, physical rehabilitation may improve IADL (standardised mean difference (SMD) 1.32, 95% confidence interval (CI) 1.08 to 1.56; 52 studies, 5403 participants; low-certainty evidence) and motor function (SMD 1.01, 95% CI 0.80 to 1.22; 50 studies, 5669 participants; low-certainty evidence). There was evidence of long-term benefits for these outcomes. Physical rehabilitation may improve balance (MD 4.54, 95% CI 1.36 to 7.72; 9 studies, 452 participants; low-certainty evidence) and likely improves gait velocity (SMD 0.23, 95% CI 0.05 to 0.42; 18 studies, 1131 participants; moderate-certainty evidence), but with no evidence of long-term benefits. Is physical rehabilitation more effective than attention control? The evidence is very uncertain about the effects of physical rehabilitation, as compared to attention control, on IADL (SMD 0.91, 95% CI 0.06 to 1.75; 2 studies, 106 participants), motor function (SMD 0.13, 95% CI -0.13 to 0.38; 5 studies, 237 participants), and balance (MD 6.61, 95% CI -0.45 to 13.66; 4 studies, 240 participants). Physical rehabilitation likely improves gait speed when compared to attention control (SMD 0.34, 95% CI 0.14 to 0.54; 7 studies, 405 participants; moderate-certainty evidence). Does additional physical rehabilitation improve outcomes? Additional physical rehabilitation may improve IADL (SMD 1.26, 95% CI 0.82 to 1.71; 21 studies, 1972 participants; low-certainty evidence) and motor function (SMD 0.69, 95% CI 0.46 to 0.92; 22 studies, 1965 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up. Additional physical rehabilitation may improve balance (MD 5.74, 95% CI 3.78 to 7.71; 15 studies, 795 participants; low-certainty evidence) and gait velocity (SMD 0.59, 95% CI 0.26 to 0.91; 19 studies, 1004 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up. Is any one approach to physical rehabilitation more effective than any other approach? Compared to other approaches, those that focus on functional task training may improve IADL (SMD 0.58, 95% CI 0.29 to 0.87; 22 studies, 1535 participants; low-certainty evidence) and motor function (SMD 0.72, 95% CI 0.21 to 1.22; 20 studies, 1671 participants; very low-certainty evidence) but the evidence in the latter is very uncertain. The benefit was sustained long-term. The evidence is very uncertain about the effect of functional task training on balance (MD 2.16, 95% CI -0.24 to 4.55) and gait velocity (SMD 0.28, 95% CI -0.01 to 0.56). Compared to other approaches, neurophysiological approaches may be less effective than other approaches in improving IADL (SMD -0.34, 95% CI -0.63 to -0.06; 14 studies, 737 participants; low-certainty evidence), and there may be no difference in improving motor function (SMD -0.60, 95% CI -1.32 to 0.12; 13 studies, 663 participants; low-certainty evidence), balance (MD -0.60, 95% CI -5.90 to 6.03; 9 studies, 292 participants; low-certainty evidence), and gait velocity (SMD -0.17, 95% CI -0.62 to 0.27; 16 studies, 630 participants; very low-certainty evidence), but the evidence is very uncertain about the effect on gait velocity. For all comparisons, the evidence is very uncertain about the effects of physical rehabilitation on adverse events and length of hospital stay. AUTHORS' CONCLUSIONS Physical rehabilitation, using a mix of different treatment components, likely improves recovery of function and mobility after stroke. Additional physical rehabilitation, delivered as an adjunct to 'usual' rehabilitation, may provide added benefits. Physical rehabilitation approaches that focus on functional task training may be useful. Neurophysiological approaches to physical rehabilitation may be no different from, or less effective than, other physical rehabilitation approaches. Certainty in this evidence is limited due to substantial heterogeneity, with mainly small studies and important differences between study populations and interventions. We feel it is unlikely that any studies published since November 2022 would alter our conclusions. Given the size of this review, future updates warrant consensus discussion amongst stakeholders to ensure the most relevant questions are explored for optimal decision-making.
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Affiliation(s)
- Alex Todhunter-Brown
- Department of Nursing and Community Health, Glasgow Caledonian University, Glasgow, UK
| | - Ceri E Sellers
- Department of Nursing and Community Health, Glasgow Caledonian University, Glasgow, UK
| | - Gillian D Baer
- Department of Physiotherapy, Queen Margaret University, Edinburgh, UK
| | - Pei Ling Choo
- Health & Social Sciences, Singapore Institute of Technology, Singapore, Singapore
| | - Julie Cowie
- Yunus Centre, Glasgow Caledonian University, Glasgow, UK
| | - Joshua D Cheyne
- UWS Library Services, University of the West of Scotland, Paisley, UK
| | - Peter Langhorne
- Academic Section of Geriatric Medicine, ICAMS, University of Glasgow, Glasgow, UK
| | | | - Jacqui Morris
- School of Health Sciences, University of Dundee, Dundee, UK
| | - Pauline Campbell
- Department of Nursing and Community Health, Glasgow Caledonian University, Glasgow, UK
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Yang SN, Kim DY. Comparing the Effectiveness of Physical Rehabilitation Interventions for Post-Stroke Function and Mobility Recovery: A Meta-Analysis. BRAIN & NEUROREHABILITATION 2023; 16:e17. [PMID: 37554258 PMCID: PMC10404812 DOI: 10.12786/bn.2023.16.e17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/21/2023] [Accepted: 06/24/2023] [Indexed: 08/10/2023] Open
Abstract
Various interventions to physical rehabilitation have been used after stroke, including musculoskeletal, neurophysiological, and motor learning interventions, with ongoing debates and controversies about their relative effectiveness. In this systematic review, we searched 3 international electronic databases (MEDLINE, Embase, and Cochrane Library) to identify relevant studies. We included only randomized controlled trials (RCTs) that directly compared motor relearning, neurophysiological, and musculoskeletal interventions for improving motor function in adult stroke patients. Risk of bias (RoB) assessment was performed using Cochrane's RoB tool, and meta-analysis was conducted using Revman 5.4 with a random effects model. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations method. The meta-analysis for immediate outcome for physical rehabilitation included 9 RCTs for balance, 10 RCTs for gait velocity, 7 RCTs for lower extremity motor function and 8 RCTs for performance of activities of daily living. There was no statistically significant different on improvement of balance, gait velocity, lower extremity motor function and performance of activity among physical rehabilitation interventions. Moderate-level evidence supports that no single intervention is superior. Clinicians and therapist should consider individual patient characteristics, preferences, and available resources when selecting the intervention for stroke rehabilitation.
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Affiliation(s)
- Seung Nam Yang
- Department of Physical Medicine and Rehabilitation, Korea University Medical Center, Seoul, Korea
| | - Doo young Kim
- Department of Rehabilitation Medicine, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
- The Convergence Institute of Healthcare and Medical Science, Catholic Kwandong University College of Medicine, Incheon, Korea
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Scrivener K, Dorsch S, McCluskey A, Schurr K, Graham PL, Cao Z, Shepherd R, Tyson S. Bobath therapy is inferior to task-specific training and not superior to other interventions in improving lower limb activities after stroke: a systematic review. J Physiother 2020; 66:225-235. [PMID: 33069609 DOI: 10.1016/j.jphys.2020.09.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 09/01/2020] [Accepted: 09/21/2020] [Indexed: 12/23/2022] Open
Abstract
QUESTION In adults with stroke, does Bobath therapy improve lower limb activity performance, strength or co-ordination when compared with no intervention or another intervention? DESIGN Systematic review of randomised trials with meta-analyses. PARTICIPANTS Adults after stroke. INTERVENTION Bobath therapy compared with another intervention or no intervention. OUTCOME MEASURES Lower limb activity performance (eg, sit to stand, walking, balance), lower limb strength and lower limb co-ordination. Trial quality was assessed using the PEDro scale. RESULTS Twenty-two trials were included in the review and 17 in the meta-analyses. The methodological quality of the trials varied, with PEDro scale scores ranging from 2 to 8 out of 10. No trials compared Bobath therapy to no intervention. Meta-analyses estimated the effect of Bobath therapy on lower limb activities compared with other interventions, including: task-specific training (nine trials), combined interventions (four trials), proprioceptive neuromuscular facilitation (one trial) and strength training (two trials). The pooled data indicated that task-specific training has a moderately greater benefit on lower limb activities than Bobath therapy (SMD 0.48), although the true magnitude of the benefit may be substantially larger or smaller than this estimate (95% CI 0.01 to 0.95). Bobath therapy did not clearly improve lower limb activities more than a combined intervention (SMD -0.06, 95% CI -0.73 to 0.61) or strength training (SMD 0.35, 95% CI -0.37 to 1.08). In one study, Bobath therapy was more effective than proprioceptive neuromuscular facilitation for improving standing balance (SMD -1.40, 95% CI -1.92 to -0.88), but these interventions did not differ on any other outcomes. Bobath therapy did not improve strength or co-ordination more than other interventions. CONCLUSIONS Bobath therapy was inferior to task-specific training and not superior to other interventions, with the exception of proprioceptive neuromuscular facilitation. Prioritising Bobath therapy over other interventions is not supported by current evidence. REGISTRATION PROSPERO CRD42019112451.
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Affiliation(s)
| | - Simone Dorsch
- Faculty of Health Sciences, Australian Catholic University, Australia; The StrokeEd Collaboration, Sydney, Australia
| | - Annie McCluskey
- The StrokeEd Collaboration, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Karl Schurr
- The StrokeEd Collaboration, Sydney, Australia
| | - Petra L Graham
- Centre for Economic Impacts of Genomic Medicine (GenIMPACT), Macquarie University, Sydney, Australia
| | | | - Roberta Shepherd
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sarah Tyson
- School of Health Sciences, University of Manchester, Manchester, UK
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Non-pharmacological interventions for the improvement of post-stroke quality of life amongst older stroke survivors: a systematic review of systematic reviews (The SENATOR ONTOP series). Eur Geriatr Med 2019; 10:359-386. [DOI: 10.1007/s41999-019-00180-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 03/08/2019] [Indexed: 11/26/2022]
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Díaz-Arribas MJ, Martín-Casas P, Cano-de-la-Cuerda R, Plaza-Manzano G. Effectiveness of the Bobath concept in the treatment of stroke: a systematic review. Disabil Rehabil 2019; 42:1636-1649. [DOI: 10.1080/09638288.2019.1590865] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- María J. Díaz-Arribas
- Department of Radiology, Rehabilitation and Physiotherapy, Faculty of Nursing, Physiotherapy and Podiatry, Complutense University of Madrid, Madrid, Spain
| | - Patricia Martín-Casas
- Department of Radiology, Rehabilitation and Physiotherapy, Faculty of Nursing, Physiotherapy and Podiatry, Complutense University of Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Roberto Cano-de-la-Cuerda
- Departament of Physiotherapy, Occupational Therapy, Rehabilitation and Physical Medicine, Faculty of Health Sciences, Rey Juan Carlos University, Alcorcón, Spain
| | - Gustavo Plaza-Manzano
- Department of Radiology, Rehabilitation and Physiotherapy, Faculty of Nursing, Physiotherapy and Podiatry, Complutense University of Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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Abuin-Porras V, Pedersini P, Berjano P, Villafañe JH. The efficacy of physical therapy on the improvement of the motor components of visual attention in children with cerebral palsy: a case series study. J Exerc Rehabil 2019; 15:103-108. [PMID: 30899744 PMCID: PMC6416505 DOI: 10.12965/jer.1836568.284] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 01/11/2019] [Indexed: 11/22/2022] Open
Abstract
This paper has attempted to compare the effects of Bobath's concept with control's session on the improvement of visual attention in children with cerebral palsy. A 10 children sample (7 girls and 3 boys) aged 6 to 16 years (median, 12 years) was collected. The group who had received Bobath-based treatment crossed-over to control treatment and the previous control group received Bobath-based treatment for once a week. Measures were assessed at pre- and posttreatment. Outcome measure included the visual attention, we used Conners' Kiddie Continuous Performance Test (K-CPT). Bobath's session targeted to crossed-over participants produced greater improvements in K-CPT(RT) (difference=33.1, P<0.05) at posttreatment compared to the control's session group, whereas the improvement of K-CPT did not differ between groups. The results of this case series study showed a significant improvement on visual attention through the improvement of motor control functions after the Bobath's session over the control's session.
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Affiliation(s)
- Vanesa Abuin-Porras
- Grupo de Investigación en dolor Musculoesquelético y Control Motor UE. Universidad Europea de Madrid, Madrid, Spain
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Bird ML, Mortenson BW, Chu F, Acerra N, Bagnall E, Wright A, Hayley K, Yao J, Eng JJ. Building a Bridge to the Community: An Integrated Knowledge Translation Approach to Improving Participation in Community-Based Exercise for People After Stroke. Phys Ther 2019; 99:286-296. [PMID: 30698783 PMCID: PMC6383711 DOI: 10.1093/ptj/pzy146] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 07/05/2018] [Indexed: 11/14/2022]
Abstract
BACKGROUND People who have had a stroke and are living in the community have low levels of physical activity, which reduces their functional capacity and increases risks of developing secondary comorbid conditions. Exercise delivered in community centers can address these low levels of physical activity; however, implementing evidence-based programs to meet the needs of all community stakeholders is challenging. OBJECTIVES The objective of this study was to determine implementation factors to facilitate participation in relevant exercise and physical activity for people with chronic health conditions, like stroke. DESIGN The design consisted of a qualitative observational study using an integrated knowledge translation approach. METHODS Supported by an integrated knowledge translation approach, a series of focus groups-with stakeholder group representation that included people who had had a stroke and care partners, community organizations (ie, support groups, community center staff), health care providers, and exercise deliverers-was conducted. During the focus groups, participants provided perspectives on factors that could influence implementation effectiveness. Focus groups were recorded, transcribed, and thematically analyzed. RESULTS Forty-eight stakeholders participated. Based on the themes, a new implementation model that describes the importance of relationships between community centers, clinicians, and people who have had a stroke is proposed. The development of partnerships facilitates the implementation and delivery of exercise programs for people with ongoing health needs. These partnerships address unmet needs articulated in the focus groups and could fill a gap in the continuity of care. CONCLUSIONS Data from this study support the need for the community sector to offer a continuing service in partnership with the health system and people with chronic health needs. It indicates the potential of clinicians to partner with people with chronic health conditions and empower them to improve participation in relevant health behaviors, like community-based exercise.
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Affiliation(s)
- Marie-Louise Bird
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - B William Mortenson
- Department of Occupational Science and Occupational Therapy, University of British Columbia
| | - Francis Chu
- Vancouver Coastal Health Authority, Community, Vancouver, British Columbia, Canada
| | - Nicole Acerra
- Vancouver Coastal Health Authority, Division of Physical Therapy
| | - Eric Bagnall
- West Vancouver Community Centre, Health and Wellness, Vancouver, British Columbia, Canada
| | | | | | - Jennifer Yao
- Vancouver Coastal Health Authority, Division of Physical Medicine and Rehabilitation
| | - Janice J Eng
- Department of Physical Therapy, University of British Columbia, 212-2177 Westbrook Mall, Vancouver, BC, V6T 1Z3 Canada,Address all correspondence to Dr Eng at:
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Chen L, Xiong S, Liu Y, Lin M, Zhu L, Zhong R, Zhao J, Liu W, Wang J, Shang X. Comparison of Motor Relearning Program versus Bobath Approach for Prevention of Poststroke Apathy: A Randomized Controlled Trial. J Stroke Cerebrovasc Dis 2019; 28:655-664. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/26/2018] [Accepted: 11/06/2018] [Indexed: 02/05/2023] Open
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Stewart C, Subbarayan S, Paton P, Gemmell E, Abraha I, Myint PK, O’Mahony D, Cruz-Jentoft AJ, Cherubini A, Soiza RL. Non-pharmacological interventions for the improvement of post-stroke activities of daily living and disability amongst older stroke survivors: A systematic review. PLoS One 2018; 13:e0204774. [PMID: 30286144 PMCID: PMC6171865 DOI: 10.1371/journal.pone.0204774] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 09/13/2018] [Indexed: 01/11/2023] Open
Abstract
Globally, stroke remains a leading cause of death and disability, with older adults disproportionately affected. Numerous non-pharmacological stroke rehabilitation approaches are in use to address impairments, but their efficacy in older persons is largely unknown. This systematic review examined the evidence for such interventions as part of the Optimal Evidence-Based Non-Drug Therapies in Older Persons (ONTOP) project conducted under an European Union funded project called the Software Engine for the Assessment and Optimisation of Drug and Non-Drug Therapies in Older Persons (SENATOR) [http://www.senator-project.eu]. A Delphi panel of European geriatric experts agreed activities of daily living and disability to be of critical importance as stroke rehabilitation outcomes. A comprehensive search strategy was developed and five databases (Pubmed, CINAHL, Embase, PsycInfo and Cochrane Database of Systematic Reviews) searched for eligible systematic reviews. Primary studies meeting our criteria (non-pharmacologic interventions, involving stroke survivors aged ≥65 years, assessing activities of daily living and/or disability as outcome) were then identified from these reviews. Eligible papers were double reviewed, and due to heterogeneity, narrative analysis performed. Cochrane risk of bias and GRADE assessment tools were used to assess bias and quality of evidence, allowing us to make recommendations regarding specific non-pharmacologic rehabilitation in older stroke survivors. In total, 72 primary articles were reviewed spanning 14 types of non-pharmacological intervention. Non-pharmacological interventions based on physiotherapy and occupational therapy techniques improved activities of daily living amongst older stroke survivors. However, no evidence was found to support use of any non-pharmacological approach to benefit older stroke survivors' disability. Evidence was limited by poor study quality and the small number of studies targeting older stroke survivors. We recommend future studies explore such interventions exclusively in older adult populations and improve methodological and outcome reporting.
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Affiliation(s)
- Carrie Stewart
- Department of Old Age Medicine, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Selvarani Subbarayan
- Department of Old Age Medicine, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
- School of Medicine & Dentistry, University of Aberdeen, Aberdeen, United Kingdom
| | - Pamela Paton
- Department of Old Age Medicine, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Elliot Gemmell
- Department of Old Age Medicine, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Iosief Abraha
- Geriatria, Accettazione geriatrica e Centro di ricerca per l’invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Phyo Kyaw Myint
- Department of Old Age Medicine, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
- School of Medicine & Dentistry, University of Aberdeen, Aberdeen, United Kingdom
| | - Denis O’Mahony
- Department of Geriatric Medicine, University College Cork, Cork, Ireland
| | - Alfonso J. Cruz-Jentoft
- Fundación para la Investigación Biomédica del Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l’invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Roy L. Soiza
- Department of Old Age Medicine, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
- School of Medicine & Dentistry, University of Aberdeen, Aberdeen, United Kingdom
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Cavuoto LA, Subryan H, Stafford M, Yang Z, Bhattacharjya S, Xu W, Langan J. Understanding User Requirements for the Design of a Home-Based Stroke Rehabilitation System. PROCEEDINGS OF THE HUMAN FACTORS AND ERGONOMICS SOCIETY ... ANNUAL MEETING. HUMAN FACTORS AND ERGONOMICS SOCIETY. ANNUAL MEETING 2018; 62:1037-1041. [PMID: 35465216 DOI: 10.1177/1541931218621239] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Limitations following stroke make it one of the leading causes of disability. The current medical pathway provides intensive care in the acute stages, but rehabilitation services are commonly discontinued after one year. While written home exercise programs are regularly prescribed at the time of discharge, compliancy is an issue. The goal of this study was to inform the design of a home-based portable rehabilitation system based on feedback from individuals with stroke and clinicians. A main component under consideration is the type and format of information feedback provided to the user, as this is hypothesized to support compliance with the rehabilitation program. From a series of focus groups and usability testing, a set of design requirements for the hardware and software were constructed. Essential features mentioned for the feedback interface included: task completion time, quality of movement, a selection of exercises, goal tracking, and a display of historical data.
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Affiliation(s)
- Lora A Cavuoto
- Department of Industrial and Systems Engineering, University at Buffalo
| | - Heamchand Subryan
- Center for Inclusive Design and Environmental Access, University at Buffalo
| | - Matthew Stafford
- Department of Computer Science and Engineering, University at Buffalo
| | - Zhuolin Yang
- Department of Computer Science and Engineering, University at Buffalo
| | | | - Wenyao Xu
- Department of Computer Science and Engineering, University at Buffalo
| | - Jeanne Langan
- Department of Rehabilitation Sciences, University at Buffalo
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Minge M, Ivanova E, Lorenz K, Joost G, Thuring M, Kruger J. BeMobil: Developing a user-friendly and motivating telerehabilitation system for motor relearning after stroke. IEEE Int Conf Rehabil Robot 2017; 2017:870-875. [PMID: 28813930 DOI: 10.1109/icorr.2017.8009358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Motor relearning after stroke is a lengthy process which should be continued after patients get discharged from the clinic. This project aims at developing a system for telerehabilitation which enables stroke patients to exercise at home autonomously or under supervision of a therapist. The system includes haptic therapy devices which are more promising and beneficial for stroke rehabilitation than non-haptic approaches. In this paper, we present the results of two initial studies investigating specific design solutions for the patient's user interface. In the first study, we developed four interactive prototypes illustrating different navigation concepts. A usability test was conducted to identify the best suitable concept. In the second study we followed a participatory design approach to create a set of design solutions for a motivating instant visual feedback for exercising with the haptic devices. The current project status and next steps are described.
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Magalhães HCDG, Menezes KKPD, Avelino PR. Efeitos do uso do Kinesio® Taping na marcha de indivíduos pós-acidente vascular encefálico: uma revisão sistemática com metanálise. FISIOTERAPIA E PESQUISA 2017. [DOI: 10.1590/1809-2950/17387024022017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO O Kinesio® Taping (KT) vem sendo utilizado na reabilitação de pacientes pós-acidente vascular encefálico (AVE) e vários estudos recentes têm investigado seus efeitos na marcha destes indivíduos, reportando resultados promissores. Investigou-se, por meio de uma revisão sistemática da literatura, os efeitos do uso do KT na marcha de indivíduos pós-AVE. As buscas foram realizadas nas bases de dados MEDLINE, CINAHL, SPORTDiscus, Web of Science, LILACS e PEDro, sem restrição de data ou idioma de publicação. Os artigos foram selecionados de forma independente por dois avaliadores e discordâncias foram resolvidas por um terceiro. A qualidade metodológica foi avaliada de acordo com a escala PEDro. Quando possível, as medidas de desfecho foram analisadas utilizando o programa Comprehensive Meta-Analysis, Versão 3.0. Foram incluídos quinze estudos de qualidade metodológica baixa a moderada (média de 4,7). Para velocidade de marcha, foram incluídos na metanálise sete estudos de qualidade metodológica baixa a moderada que, sob o modelo de efeitos fixos, encontrou que o KT aumentou significativamente a velocidade de marcha dos indivíduos pós-AVE em 0,05 m/s (95% IC 0,002 a 0,100; I2 = 0%; p<0.05). No entanto, para o comprimento do passo, mobilidade funcional e equilíbrio não houve diferença significativa (p>0,05). Esta revisão sistemática da literatura demonstrou que ainda não existem evidências sobre o uso do KT na reabilitação de pacientes pós-AVE com o objetivo de melhorar a marcha. Embora a velocidade de marcha, segundo a metanálise, tenha apresentado um ganho estatisticamente significativo, seu valor não pode ser considerado clinicamente relevante para os pacientes.
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Ivanova E, Minge M, Schmidt H, Thüring M, Krüger J. User-centered design of a patient’s work station for haptic robot-based telerehabilitation after stroke. CURRENT DIRECTIONS IN BIOMEDICAL ENGINEERING 2017. [DOI: 10.1515/cdbme-2017-0009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract:Robotic therapy devices have been an important part of clinical neurological rehabilitation for several years. Until now such devices are only available for patients receiving therapy inside rehabilitation hospitals. Since patients should continue rehabilitation training after hospital discharge at home, intelligent robotic rehab devices could help to achieve this goal. This paper presents therapeutic requirements and early phases of the user-centered design process of the patient’s work station as part of a novel robot-based system for motor telerehabilitation.
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Affiliation(s)
- Ekaterina Ivanova
- 1Rehabilitation Robotics Group, Chair of Industrial Automation Technology, TU Berlin, Berlin, Germany
| | - Michael Minge
- 2Cognitive Psychology and Cognitive Ergonomics, TU Berlin, Berlin, Germany
| | - Henning Schmidt
- 3Rehabilitation Robotics Group, Fraunhofer IPK, Berlin, Germany
| | - Manfred Thüring
- 2Cognitive Psychology and Cognitive Ergonomics, TU Berlin, Berlin, Germany
| | - Jörg Krüger
- 4Chair of Industrial Automation Technology, TU Berlin, Berlin, Germany
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French B, Thomas LH, Coupe J, McMahon NE, Connell L, Harrison J, Sutton CJ, Tishkovskaya S, Watkins CL, Cochrane Stroke Group. Repetitive task training for improving functional ability after stroke. Cochrane Database Syst Rev 2016; 11:CD006073. [PMID: 27841442 PMCID: PMC6464929 DOI: 10.1002/14651858.cd006073.pub3] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation. OBJECTIVES Primary objective: To determine if RTT improves upper limb function/reach and lower limb function/balance in adults after stroke. Secondary objectives: 1) To determine the effect of RTT on secondary outcome measures including activities of daily living, global motor function, quality of life/health status and adverse events. 2) To determine the factors that could influence primary and secondary outcome measures, including the effect of 'dose' of task practice; type of task (whole therapy, mixed or single task); timing of the intervention and type of intervention. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (4 March 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 5: 1 October 2006 to 24 June 2016); MEDLINE (1 October 2006 to 8 March 2016); Embase (1 October 2006 to 8 March 2016); CINAHL (2006 to 23 June 2016); AMED (2006 to 21 June 2016) and SPORTSDiscus (2006 to 21 June 2016). SELECTION CRITERIA Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal. DATA COLLECTION AND ANALYSIS Two review authors independently screened abstracts, extracted data and appraised trials. We determined the quality of evidence within each study and outcome group using the Cochrane 'Risk of bias' tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. We did not assess follow-up outcome data using GRADE. We contacted trial authors for additional information. MAIN RESULTS We included 33 trials with 36 intervention-control pairs and 1853 participants. The risk of bias present in many studies was unclear due to poor reporting; the evidence has therefore been rated 'moderate' or 'low' when using the GRADE system. There is low-quality evidence that RTT improves arm function (standardised mean difference (SMD) 0.25, 95% confidence interval (CI) 0.01 to 0.49; 11 studies, number of participants analysed = 749), hand function (SMD 0.25, 95% CI 0.00 to 0.51; eight studies, number of participants analysed = 619), and lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48; five trials, number of participants analysed = 419). There is moderate-quality evidence that RTT improves walking distance (mean difference (MD) 34.80, 95% CI 18.19 to 51.41; nine studies, number of participants analysed = 610) and functional ambulation (SMD 0.35, 95% CI 0.04 to 0.66; eight studies, number of participants analysed = 525). We found significant differences between groups for both upper-limb (SMD 0.92, 95% CI 0.58 to 1.26; three studies, number of participants analysed = 153) and lower-limb (SMD 0.34, 95% CI 0.16 to 0.52; eight studies, number of participants analysed = 471) outcomes up to six months post treatment but not after six months. Effects were not modified by intervention type, dosage of task practice or time since stroke for upper or lower limb. There was insufficient evidence to be certain about the risk of adverse events. AUTHORS' CONCLUSIONS There is low- to moderate-quality evidence that RTT improves upper and lower limb function; improvements were sustained up to six months post treatment. Further research should focus on the type and amount of training, including ways of measuring the number of repetitions actually performed by participants. The definition of RTT will need revisiting prior to further updates of this review in order to ensure it remains clinically meaningful and distinguishable from other interventions.
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Affiliation(s)
- Beverley French
- University of Central LancashireDepartment of Nursing and Caring SciencesRoom 434Brook BuildingPrestonLancashireUKPR1 2HE
| | - Lois H Thomas
- University of Central LancashireCollege of Health and WellbeingRoom 326Brook BuildingPrestonLancashireUKPR1 2HE
| | - Jacqueline Coupe
- University of Central LancashireCollege of Health and WellbeingRoom 326Brook BuildingPrestonLancashireUKPR1 2HE
| | - Naoimh E McMahon
- University of Central LancashireCollege of Health and WellbeingRoom 326Brook BuildingPrestonLancashireUKPR1 2HE
| | - Louise Connell
- University of Central LancashireCollege of Health and WellbeingRoom 326Brook BuildingPrestonLancashireUKPR1 2HE
| | - Joanna Harrison
- University of Central LancashireDepartment of NursingPrestonLancashireUKPR1 2HE
| | - Christopher J Sutton
- University of Central LancashireCollege of Health and WellbeingRoom 326Brook BuildingPrestonLancashireUKPR1 2HE
| | | | - Caroline L Watkins
- University of Central LancashireCollege of Health and WellbeingRoom 326Brook BuildingPrestonLancashireUKPR1 2HE
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Brkic L, Shaw L, van Wijck F, Francis R, Price C, Forster A, Langhorne P, Watkins C, Rodgers H. Repetitive arm functional tasks after stroke (RAFTAS): a pilot randomised controlled trial. Pilot Feasibility Stud 2016; 2:50. [PMID: 27965867 PMCID: PMC5154114 DOI: 10.1186/s40814-016-0088-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 07/28/2016] [Indexed: 11/30/2022] Open
Abstract
Background Repetitive functional task practise (RFTP) is a promising treatment to improve upper limb recovery following stroke. We report the findings of a study to determine the feasibility of a multi-centre randomised controlled trial to evaluate this intervention. Methods A pilot randomised controlled trial recruited patients with new reduced upper limb function within 14 days of acute stroke from three stroke units. Participants were randomised to receive a four week upper limb RFTP therapy programme consisting of goal setting, independent activity practise, and twice weekly therapy reviews in addition to usual post stroke rehabilitation, or usual post stroke rehabilitation. The recruitment rate; adherence to the RFTP therapy programme; usual post stroke rehabilitation received; attrition rate; data quality; success of outcome assessor blinding; adverse events; and the views of study participants and therapists about the intervention were recorded. Results Fifty five eligible patients were identified, 4-6 % of patients screened at each site. Twenty four patients participated in the pilot study. Two study sites met the recruitment target of 1–2 participants per month. The median number of face to face therapy sessions received was 6 [IQR 3–8]. The median number of daily repetitions of activities recorded was 80 [IQR 39–80]. Data about usual post stroke rehabilitation were available for 18/24 (75 %). Outcome data were available for 22/24 (92 %) at one month and 20/24 (83 %) at three months. Outcome assessors were unblinded to participant group allocation for 11/22 (50 %) at one month and 6/20 (30 %) at three months. Four adverse events were considered serious as they resulted in hospitalisation. None were related to study treatment. Feedback from patients and therapists about the RFTP programme was mainly positive. Conclusions A multi-centre randomised controlled trial to evaluate an upper limb RFTP therapy programme provided early after stroke is feasible and acceptable to patients and therapists, but there are issues which need to be addressed when designing a Phase III study. A Phase III study will need to monitor and report not only recruitment and attrition but also adherence to the intervention, usual post stroke rehabilitation received, and outcome assessor blinding. Trial registration International Standard Randomised Controlled Trials Number (ISRCTN) 58527251
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Affiliation(s)
- Lianne Brkic
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Frederike van Wijck
- Institute for Applied Health Research and School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA UK
| | - Richard Francis
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Christopher Price
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Anne Forster
- Academic Unit of Elderly Care and Rehabilitation, Bradford Royal Infirmary, University of Leeds and Bradford Institute for Health Research, Duckworth Lane, Bradford, BD9 6RJ UK
| | - Peter Langhorne
- Academic Section of Geriatric Medicine, Royal Infirmary, Floor 2, New Lister Building, Glasgow, G31 2ER UK
| | - Caroline Watkins
- Clinical Practice Research Unit, School of Nursing and Caring Sciences, University of Central Lancashire, Brook 419, Preston, PR1 2HE UK
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
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Langhammer B, Lindmark B, Stanghelle JK. Stroke patients and long-term training: is it worthwhile? A randomized comparison of two different training strategies after rehabilitation. Clin Rehabil 2016; 21:495-510. [PMID: 17613581 DOI: 10.1177/0269215507075207] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective : To find out if there were any differences in improvement and maintenance of motor function, activity of daily living and grip strength between patients with first-ever stroke receiving two different strategies of physical exercise during the first year after stroke. Design : A longitudinal randomized controlled stratified trial. Setting : Rehabilitation institutions, community, patients' homes and nursing homes. Subjects : Seventy-five male and female first-time-ever stroke patients: 35 in an intensive exercise group and 40 in a regular exercise group. Intervention : The intensive exercise group received physiotherapy with focus on intensive exercises in four periods during the first year after stroke. The regular exercise group patients were followed up according to their subjective needs during the corresponding year. Main outcome measures : Motor Assessment Scale, Barthel Index of Activities of Daily Living, and grip strength. Results : Both groups improved significantly up to six months when function stabilized. The groups did not differ significantly on any test occasions. The difference of improvement from admission to discharge was significant in favour of the intensive exercise group, in the Motor Assessment Scale total score (intensive exercise group 7.5; regular exercise group 1.7, P = 0.01), and in the Barthel Index of Activities of Daily Living total score (17.4 versus 8.9, P = 0.04). Conclusion : Motor function, activities of daily living functions and grip strength improved initially and were maintained during the first year after stroke in all patients irrespective of exercise regime. This indicates the importance of motivation for regular exercise in the first year following stroke, achieved by regular check-ups.
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Affiliation(s)
- Birgitta Langhammer
- Oslo University College, Faculty of Health, Physiotherapy Programme, Oslo, Norway.
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Şimşek TT, Çekok K. The effects of Nintendo Wii(TM)-based balance and upper extremity training on activities of daily living and quality of life in patients with sub-acute stroke: a randomized controlled study. Int J Neurosci 2015; 126:1061-70. [PMID: 26626539 DOI: 10.3109/00207454.2015.1115993] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the effects of Nintendo Wii(TM)-based balance and upper extremity training on activities of daily living and quality of life in patients with subacute stroke. METHODS 42 adults with stroke (mean age (SD) = 58.04 (16.56) years and mean time since stroke (SD) = (55.2 ± 22.02 days (∼8 weeks)) were included in the study. Participants were enrolled from the rehabilitation department of a medical center (a single inpatient rehabilitation facility). Participants were randomly assigned to Nintendo Wii group (n = 20) or Bobath neurodevelopmental treatment (NDT) (n = 22). The treatments were applied for 10 weeks (45-60 minutes/day, 3 days/week) for both of two groups. Nintendo Wii group used five games selected from the Wii sports and Wii Fit packages for upper limb and balance training, respectively. The patients in Bobath NDT group were applied a therapy program included upper extremity activites, strength, balance gait and functional training. The functional independence in daily life activities and health-related quality of life was assessed with Functional Independence Measure (FIM) and Nottingham Health Profile (NHP), respectively. Participant's treatment satisfaction was recorded by using Visual Analogue Scale. A second evaluation (FIM and NHP) occurred after 10 weeks at the end of rehabilitative treatment (post-training). Treatment satisfaction was measured after 10 sessions. RESULTS There were significant difference between FIM and NHP values in NDT and Nintendo Wii group (p < 0.05). However, a significant difference was not found between the groups with regard to FIM and NHP (p > 0.05). The patients in Nintendo Wii group were detected to be better satisfied from the therapy (p < 0.05). A significant difference was found between subparameters and total FIM score, all subparameters and total NHP score in both groups (p < 0.05). CONCLUSION These findings suggested that the Nintendo Wii training was as effective as Bobath NDT on daily living functions and quality of life in subacute stroke patients.
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Affiliation(s)
- Tülay Tarsuslu Şimşek
- a School of Physical Therapy and Rehabilitation , Dokuz Eylül University , İzmir , Turkey
| | - Kübra Çekok
- b Department of Physical Therapy and Rehabilitation , Medicalpark Izmir Hospital , İzmir , Turkey
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Abdollahi I, Taghizadeh A, Shakeri H, Eivazi M, Jaberzadeh S. The relationship between isokinetic muscle strength and spasticity in the lower limbs of stroke patients. J Bodyw Mov Ther 2015; 19:284-90. [DOI: 10.1016/j.jbmt.2014.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Revised: 07/08/2014] [Accepted: 07/10/2014] [Indexed: 12/16/2022]
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Bambirra C, Rodrigues MCDB, Faria CDCDM, Paula FRD. Clinical evaluation of balance in hemiparetic adults: a systematic review. FISIOTERAPIA EM MOVIMENTO 2015. [DOI: 10.1590/0103-5150.028.001.ar03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Hemiparesis is a common post-stroke impairment often associated with balance deficits. Standardized instruments for balance assessment may be useful in identifying individuals at risk of falling and evaluating intervention outcomes. Objectives To identify instruments with adequate psychometric properties and clinical application to assess balance in hemiparetic cases within the scope of physiotherapy and to verify tools most frequently used in studies that evaluated the effects of therapeutic interventions in order to improve the balance of hemiparetic patients. Methods A search was conducted in the Medline, Lilacs, PEDro, and Web of Science databases by two independent researchers, who selected and analyzed studies that evaluated the reliability and validity of balance assessment instruments and intervention results. Results and discussion The Berg Balance Scale was the most frequently used instrument in the intervention studies. Nine single-task tests (timed up and go, functional reach test, step test, four-square step test, side step test, supported standing balance, standing arm raise, static tandem standing, and weight shifting) and six multiple-task tests (Berg balance scale, Brunel balance assessment, Fugl-Meyer Assessment/balance section, mini balance evaluation systems test, and postural assessment scale for stroke patients) demonstrated adequate psychometric properties and clinical applications to assess balance in hemiparetic individuals. Conclusions The Berg Balance Scale had the most widely studied psychometric properties and was the most frequently used scale in the intervention studies. Further studies are required to validate and adapt other instruments for the Brazilian population.
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Khadilkar A, Phillips K, Jean N, Lamothe C, Milne S, Sarnecka J. Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation. Top Stroke Rehabil 2015; 13:1-269. [PMID: 16939981 DOI: 10.1310/3tkx-7xec-2dtg-xqkh] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA). METHOD Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale. RESULTS The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation. DISCUSSION AND CONCLUSION The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.
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Bayona NA, Bitensky J, Salter K, Teasell R. The Role of Task-Specific Training in Rehabilitation Therapies. Top Stroke Rehabil 2015; 12:58-65. [PMID: 16110428 DOI: 10.1310/bqm5-6ygb-mvj5-wvcr] [Citation(s) in RCA: 203] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Task-oriented therapy is important. It makes intuitive sense that the best way to relearn a given task is to train specifically for that task. In animals, functional reorganization is greater for tasks that are meaningful to the animal. Repetition alone, without usefulness or meaning in terms of function, is not enough to produce increased motor cortical representations. In humans, less intense but task-specific training regimens with the more affected limb can produce cortical reorganization and associated, meaningful functional improvements.
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Affiliation(s)
- Nestor A Bayona
- Department of Physical Medicine and Rehabilitation, St. Joseph's Health Care and the University of Western Ontario, London, Ontario, Canada
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Ertelt D, Binkofski F. Action observation as a tool for neurorehabilitation to moderate motor deficits and aphasia following stroke. Neural Regen Res 2015; 7:2063-74. [PMID: 25624838 PMCID: PMC4296427 DOI: 10.3969/j.issn.1673-5374.2012.26.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 06/30/2012] [Indexed: 01/05/2023] Open
Abstract
The mirror neuron system consists of a set of brain areas capable of matching action observation with action execution. One core feature of the mirror neuron system is the activation of motor areas by action observation alone. This unique capacity of the mirror neuron system to match action perception and action execution stimulated the idea that mirror neuron system plays a crucial role in the understanding of the content of observed actions and may participate in procedural learning. These features bear a high potential for neurorehabilitation of motor deficits and of aphasia following stroke. Since the first articles exploring this principle were published, a growing number of follow-up studies have been conducted in the last decade. Though, the combination of action observation with practice of the observed actions seems to constitute the most powerful approach. In the present review, we present the existing studies analyzing the effects of this neurorehabilitative approach in clinical settings especially in the rehabilitation of stroke associated motor deficits and give a perspective on the ongoing trials by our research group. The data obtained up to date showed significant positive effect of action observation on recovery of motor functions of the upper limbs even in the chronic state after stroke, indicating that our approach might become a new standardized add-on feature of modern neurorehabilitative treatment schemes.
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Affiliation(s)
- Denis Ertelt
- Center for Clinical Trials, University of Luebeck, University Hospital Schleswig-Holstein - Campus Luebeck, Lübeck 23562, Schleswig-Holstein, Germany
| | - Ferdinand Binkofski
- Cognitive Neurology, Department of Neurology, RWTH Aachen University Hospital, Aachen 52062, North Rhine-Westphalia, Germany
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Paquin K, Ali S, Carr K, Crawley J, McGowan C, Horton S. Effectiveness of commercial video gaming on fine motor control in chronic stroke within community-level rehabilitation. Disabil Rehabil 2015; 37:2184-91. [PMID: 25586794 DOI: 10.3109/09638288.2014.1002574] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE The purpose of this study was to investigate the effectiveness of commercial gaming as an intervention for fine motor recovery in chronic stroke. METHODS Ten chronic phase post-stroke participants (mean time since CVA = 39 mos; mean age = 72 yrs) completed a 16-session program using the Nintendo Wii for 15 min two times per week with their more affected hand (10 right handed). Functional recovery (Jebsen Hand Function Test (JHFT), Box and Block Test (BBT), Nine Hole Peg Test (NHPT)), and quality of life (QOL; Stroke Impact Scale (SIS)) were measured at baseline (pre-testing), after 8 sessions (mid-testing) and after 16 sessions (post-testing). RESULTS Significant improvements were found with the JHFT, BBT and NHPT from pre-testing to post-testing (p = 0.03, p = 0.03, p = 0.01, respectively). As well, there was an increase in perceived QOL from pre-testing to post-testing, as determined by the SIS (p = 0.009). CONCLUSION Commercial gaming may be a viable resource for those with chronic stroke. Future research should examine the feasibility of this as a rehabilitation tool for this population. IMPLICATIONS FOR REHABILITATION Stroke survivors often live with lasting effects from their injury, however, those with chronic stroke generally receive little to no rehabilitation due to a perceived motor recovery plateau. Virtual reality in the form of commercial gaming is a novel and motivating way for clients to complete rehabilitation. The Nintendo Wii may be a feasible device to improve both functional ability and perceived quality of life in chronic stroke survivors.
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Affiliation(s)
| | | | | | - Jamie Crawley
- b Faculty of Nursing , University of Windsor , Windsor , Ontario , Canada
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Cao J, Xie SQ, Das R, Zhu GL. Control strategies for effective robot assisted gait rehabilitation: The state of art and future prospects. Med Eng Phys 2014; 36:1555-66. [DOI: 10.1016/j.medengphy.2014.08.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 08/01/2014] [Accepted: 08/12/2014] [Indexed: 11/29/2022]
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Chen JC, Shaw FZ. Progress in sensorimotor rehabilitative physical therapy programs for stroke patients. World J Clin Cases 2014; 2:316-326. [PMID: 25133141 PMCID: PMC4133420 DOI: 10.12998/wjcc.v2.i8.316] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 05/15/2014] [Accepted: 07/14/2014] [Indexed: 02/05/2023] Open
Abstract
Impaired motor and functional activity following stroke often has negative impacts on the patient, the family and society. The available rehabilitation programs for stroke patients are reviewed. Conventional rehabilitation strategies (Bobath, Brunnstrom, proprioception neuromuscular facilitation, motor relearning and function-based principles) are the mainstream tactics in clinical practices. Numerous advanced strategies for sensory-motor functional enhancement, including electrical stimulation, electromyographic biofeedback, constraint-induced movement therapy, robotics-aided systems, virtual reality, intermittent compression, partial body weight supported treadmill training and thermal stimulation, are being developed and incorporated into conventional rehabilitation programs. The concept of combining valuable rehabilitative procedures into “a training package”, based on the patient’s functional status during different recovery phases after stroke is proposed. Integrated sensorimotor rehabilitation programs with appropriate temporal arrangements might provide great functional benefits for stroke patients.
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Changes in Functional Outcomes in Elderly Patients as a Result of Poststroke Rehabilitation Using the NDT-Bobath Method. TOPICS IN GERIATRIC REHABILITATION 2014. [DOI: 10.1097/tgr.0000000000000029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Langhammer B, Lindmark B, Stanghelle JK. 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. Brain Inj 2014; 28:1396-405. [DOI: 10.3109/02699052.2014.919534] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Pollock A, Baer G, Campbell P, Choo PL, Forster A, Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database Syst Rev 2014; 2014:CD001920. [PMID: 24756870 PMCID: PMC6465059 DOI: 10.1002/14651858.cd001920.pub3] [Citation(s) in RCA: 233] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches. OBJECTIVES To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.For the previous versions of this review, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate individual treatment components, categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation. SELECTION CRITERIA Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches. DATA COLLECTION AND ANALYSIS Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data. MAIN RESULTS We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions. AUTHORS' CONCLUSIONS Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.
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Affiliation(s)
- Alex Pollock
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Buchanan House, Cowcaddens Road, Glasgow, UK, G4 0BA
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Pollock A, Baer G, Campbell P, Choo PL, Forster A, Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Hippokratia 2014. [PMID: 24756870 DOI: 10.1002/14651858.cd001920.pub3#sthash.keppcclr.dpuf] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches. OBJECTIVES To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.For the previous versions of this review, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate individual treatment components, categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation. SELECTION CRITERIA Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches. DATA COLLECTION AND ANALYSIS Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data. MAIN RESULTS We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions. AUTHORS' CONCLUSIONS Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.
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Affiliation(s)
- Alex Pollock
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Buchanan House, Cowcaddens Road, Glasgow, UK, G4 0BA
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Combs-Miller SA, Kalpathi Parameswaran A, Colburn D, Ertel T, Harmeyer A, Tucker L, Schmid AA. Body weight-supported treadmill training vs. overground walking training for persons with chronic stroke: a pilot randomized controlled trial. Clin Rehabil 2014; 28:873-84. [PMID: 24519922 DOI: 10.1177/0269215514520773] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare the effects of body weight-supported treadmill training and overground walking training when matched for task and dose (duration/frequency/intensity) on improving walking function, activity, and participation after stroke. DESIGN Single-blind, pilot randomized controlled trial with three-month follow-up. SETTINGS University and community settings. SUBJECTS A convenience sample of participants (N = 20) at least six months post-stroke and able to walk independently were recruited. INTERVENTIONS Thirty-minute walking interventions (body weight-supported treadmill training or overground walking training) were administered five times a week for two weeks. Intensity was monitored with the Borg Rating of Perceived Exertion Scale at five-minute increments to maintain a moderate training intensity. MAIN MEASURES Walking speed (comfortable/fast 10-meter walk), walking endurance (6-minute walk), spatiotemporal symmetry, and the ICF Measure of Participation and ACTivity were assessed before, immediately after, and three months following the intervention. RESULTS The overground walking training group demonstrated significantly greater improvements in comfortable walking speed compared with the body weight-supported treadmill training group immediately (change of 0.11 m/s vs. 0.06 m/s, respectively; p = 0.047) and three months (change of 0.14 m/s vs. 0.08 m/s, respectively; p = 0.029) after training. Only the overground walking training group significantly improved comfortable walking speed (p = 0.001), aspects of gait symmetry (p = 0.032), and activity (p = 0.003) immediately after training. Gains were maintained at the three-month follow-up (p < 0.05) for all measures except activity. Improvements in participation were not demonstrated. CONCLUSION Overgound walking training was more beneficial than body weight-supported treadmill training at improving self-selected walking speed for the participants in this study.
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Affiliation(s)
| | | | - Dawn Colburn
- Krannert School of Physical Therapy, University of Indianapolis, IN, USA
| | - Tara Ertel
- Krannert School of Physical Therapy, University of Indianapolis, IN, USA
| | - Amanda Harmeyer
- Krannert School of Physical Therapy, University of Indianapolis, IN, USA
| | - Lindsay Tucker
- Krannert School of Physical Therapy, University of Indianapolis, IN, USA
| | - Arlene A Schmid
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO, USA
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Veerbeek JM, van Wegen E, van Peppen R, van der Wees PJ, Hendriks E, Rietberg M, Kwakkel G. What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PLoS One 2014; 9:e87987. [PMID: 24505342 PMCID: PMC3913786 DOI: 10.1371/journal.pone.0087987] [Citation(s) in RCA: 732] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 12/30/2013] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT. METHODS AND FINDINGS Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N = 25373; median PEDro score 6 [IQR 5-7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03-0.70; I(2) = 0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84-4.11; I(2) = 77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02-0.39; I(2) = 6%) for motor function of the paretic arm to 0.61 (95%CI 0.41-0.82; I(2) = 41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing. CONCLUSIONS There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.
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Affiliation(s)
- Janne Marieke Veerbeek
- Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Erwin van Wegen
- Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Roland van Peppen
- Department of Physiotherapy, University of Applied Sciences Utrecht, Utrecht, The Netherlands
| | - Philip Jan van der Wees
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Erik Hendriks
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Marc Rietberg
- Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Gert Kwakkel
- Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
- Department of Neurorehabilitation, Reade Center for Rehabilitation and Rheumatology, Amsterdam, The Netherlands
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Langan J, Delave K, Phillips L, Pangilinan P, Brown SH. Home-based telerehabilitation shows improved upper limb function in adults with chronic stroke: a pilot study. J Rehabil Med 2013; 45:217-20. [PMID: 23319181 DOI: 10.2340/16501977-1115] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This pilot study investigates the use of telerehabilitation to improve upper limb performance in chronic stages of stroke recovery. DESIGN Intervention study with pre/post/one month follow-up tests. METHODS Seven adults with chronic stroke participated in the study. Tests consisted of lab-based clinical and kinematic assessments. Participants completed the Upper Limb Training and Assessment (ULTrA) program at home. Training was 5 days/week, 60 min/day for 6 weeks with intermittent supervision of participants. RESULTS Participants showed improvements in the training program tasks as well as clinical and kinematic assessments. Results also suggest there may be auxiliary benefits in cognitive function. CONCLUSIONS A home-based telerehabilitation program is a viable approach to provide rehabilitation in chronic stages of stroke.
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Affiliation(s)
- Jeanne Langan
- School of Kinesiology, University of Michigan, Ann Arbor, MI, USA.
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Saywell N, Vandal AC, Brown P, Hanger HC, Hale L, Mudge S, Milosavljevic S, Feigin V, Taylor D. Telerehabilitation to improve outcomes for people with stroke: study protocol for a randomised controlled trial. Trials 2012; 13:233. [PMID: 23216861 PMCID: PMC3543302 DOI: 10.1186/1745-6215-13-233] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 11/14/2012] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In New Zealand, around 45,000 people live with stroke and many studies have reported that benefits gained during initial rehabilitation are not sustained. Evidence indicates that participation in physical interventions can prevent the functional decline that frequently occurs after discharge from acute care facilities. However, on-going stroke services provision following discharge from acute care is often related to non-medical factors such as availability of resources and geographical location. Currently most people receive no treatment beyond three months post stroke. The study aims to determine if the Augmented Community Telerehabilitation Intervention (ACTIV) results in better physical function for people with stroke than usual care, as measured by the Stroke Impact Scale, physical subcomponent. METHODS/DESIGN This study will use a multi-site, two-arm, assessor blinded, parallel randomised controlled trial design. People will be eligible if they have had their first ever stroke, are over 20 and have some physical impairment in either arm or leg, or both. Following discharge from formal physiotherapy services (inpatient, outpatient or community), participants will be randomised into ACTIV or usual care. ACTIV uses readily available technology, telephone and mobile phones, combined with face-to-face visits from a physiotherapist over a six-month period, to help people with stroke resume activities they enjoyed before the stroke. The impact of stroke on physical function and quality of life will be assessed, measures of cost will be collected and a discrete choice survey will be used to measure preferences for rehabilitation options. These outcomes will be collected at baseline, six months and 12 months. In-depth interviews will be used to explore the experiences of people participating in the intervention arm of the study. DISCUSSION The lack of on-going rehabilitation for people with stroke diminishes the chance of their best possible outcome and may contribute to a functional decline following discharge from formal rehabilitation. Best practice guidelines recommend a prolonged period of rehabilitation, however this is expensive and therefore not undertaken in most publicly funded centres. An effective, cost-effective, and preference-sensitive therapy using basic technology to assist programme delivery may improve patient autonomy as they leave formal rehabilitation and return home. TRIAL REGISTRATION ACTRN12612000464864.
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Affiliation(s)
- Nicola Saywell
- Health and Rehabilitation Research Institute, AUT University, Private Bag 92006, Auckland, 1142, New Zealand.
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Pundik S, Holcomb J, McCabe J, Daly JJ. Enhanced life-role participation in response to comprehensive gait training in chronic stroke survivors*. Disabil Rehabil 2012; 34:2264-71. [DOI: 10.3109/09638288.2012.696875] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Pundik S, Holcomb J, McCabe J, Daly JJ. Enhanced life-role participation in response to comprehensive gait training in chronic-stroke survivors. Disabil Rehabil 2012; 34:1535-9. [DOI: 10.3109/09638288.2011.650308] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Langhammer B, Lindmark B. Functional exercise and physical fitness post stroke: the importance of exercise maintenance for motor control and physical fitness after stroke. Stroke Res Treat 2012; 2012:864835. [PMID: 22315707 PMCID: PMC3270468 DOI: 10.1155/2012/864835] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 09/15/2011] [Accepted: 10/11/2011] [Indexed: 11/17/2022] Open
Abstract
It is argued that all stroke patients, indifferent of disability, have the same possibility to improve with training. The aim of the study was to follow and register functional improvements in two groups with different functional capacities at baseline for a period of 36 months. Stroke patients were recruited and divided into groups related to their functional status at baseline. During the acute rehabilitation, both groups received functional task-oriented training, followed by regular self- or therapeutic driven training the first year after stroke and varied exercise patterns the following 24 months. The participants were tested on admission, and at three, six, twelve, and thirty-six months after the onset of stroke. Both groups improved functional activity up to six months which then stabilized up to twelve months to decline somewhat at thirty-six months after stroke. Change scores indicate a greater potential for rehabilitation in the MAS ≤35 in relation to group MAS >35 although the functional capacity was higher in the latter. This indicates the importance of maintaining exercise and training for all persons after stroke.
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Affiliation(s)
- Birgitta Langhammer
- Physiotherapy Programme, Faculty of Health Sciences, Oslo University College, Box 4, Sanct Olavs pl, 0130 Oslo, Norway
| | - Birgitta Lindmark
- Physiotherapy, University Hospital, Department of Neuroscience, Uppsala University, Entrance 15, 751 85 Uppsala, Sweden
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Choi M, Lee D, Ro H. Effect of Task-oriented Training and Neurodevelopmental Treatment on the Sitting Posture in Children with Cerebral Palsy. J Phys Ther Sci 2011. [DOI: 10.1589/jpts.23.323] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Munhee Choi
- Department of Physical Therapy, Daedong hospital
| | - Daehee Lee
- Department of Physical Therapy, Youngdong University
| | - Hyolyun Ro
- Department of Occupational Therapy, Kangwon National University
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Patterson KK, Gage WH, Brooks D, Black SE, McIlroy WE. Changes in Gait Symmetry and Velocity After Stroke: A Cross-Sectional Study From Weeks to Years After Stroke. Neurorehabil Neural Repair 2010; 24:783-90. [DOI: 10.1177/1545968310372091] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. There is little information about the quality of gait in the years following stroke. Long-term changes in mobility, using global indices of function, suggest a decline well after initial rehabilitation. However, global indices of mobility do not reveal more specific changes in walking competency or underlying gait-specific impairment. Objectives. The authors used a cross-sectional design with gait-specific measures (velocity and symmetry) to investigate whether deterioration in gait occurs over the long term poststroke. Methods. Data were abstracted from a standardized database containing clinical assessments and spatiotemporal gait analyses for 171 individuals with stroke. Velocity and 3 expressions of symmetry ratios (swing time, stance time, and step length) were calculated for each individual; they were then assigned to 1 of the 5 following groups: 0 to 3, 3 to 12, 12 to 24, 24 to 48, and >48 months poststroke. Results. Swing time, stance time, and step length symmetry demonstrated a systematic linear trend toward greater asymmetry in groups in the later stages poststroke, whereas velocity, neurological deficit, and lower-extremity (LE) motor impairment did not. Conclusions. The quality of gait, as measured by spatial and temporal symmetry, appears to worsen in later years. These results suggest a dissociation between quantitative measures of gait, such as velocity versus symmetry, and that these parameters may measure independent features. A longitudinal study is needed to confirm the presence and to interpret the clinical meaning of a long-term decline in specific parameters of poststroke gait.
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Affiliation(s)
- Kara K. Patterson
- University of Toronto, Toronto, ON, Canada, Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - William H. Gage
- Toronto Rehabilitation Institute, Toronto, ON, Canada, York University, Toronto, ON, Canada
| | - Dina Brooks
- University of Toronto, Toronto, ON, Canada, Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Sandra E. Black
- University of Toronto, Toronto, ON, Canada, Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - William E. McIlroy
- University of Toronto, Toronto, ON, Canada, Toronto Rehabilitation Institute, Toronto, ON, Canada, University of Waterloo, Waterloo, ON, Canada,
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Giriko CH, Azevedo RAN, Kuriki HU, Carvalho ACD. Capacidade funcional de hemiparéticos crônicos submetidos a um programa de fisioterapia em grupo. FISIOTERAPIA E PESQUISA 2010. [DOI: 10.1590/s1809-29502010000300005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Este estudo tem como objetivos analisar a eficácia da fisioterapia em grupo sobre a marcha, o equilíbrio corporal e o risco de queda, e verificar se há correlação entre a capacidade funcional da marcha e o equilíbrio em indivíduos com hemiparesia crônica. Participaram do estudo 21 adultos hemiparéticos, com idade média de 58,9±10,6 anos, com seqüela de no mínimo 1 ano após acidente vascular encefálico isquêmico ou hemorrágico. Os sujeitos foram submetidos a um programa de 1 hora de fisioterapia em grupo duas vezes por semana durante seis meses. Foram avaliados por meio da escala de equilíbrio de Berg (EEB) e do teste de levantar e caminhar cronometrado TLCC (TUG, na sigla em inglês de timed up & go) antes do programa, após 13 e ao fim de 26 semanas. Os resultados mostram uma redução progressiva, embora não-significativa, no tempo de execução do TLCC e aumento progressivo, também não-significativo, do escore na EEB. Foi observada forte correlação entre as duas escalas (r=0,7, p<0,05). Assim, a terapia não foi efetiva para produzir melhora nos escores dos testes, mas contribuiu para manter a mobilidade.
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Bensoussan L, Mathelin A, Viton JM, Collado H, Delarque A. Improvement of gait in a stroke patient. A 7-year longitudinal study. Disabil Rehabil 2010; 32:1705-11. [DOI: 10.3109/09638281003649953] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Tyedin K, Cumming TB, Bernhardt J. Quality of life: An important outcome measure in a trial of very early mobilisation after stroke. Disabil Rehabil 2009; 32:875-84. [DOI: 10.3109/09638280903349552] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Brock K, Black S, Cotton S, Kennedy G, Wilson S, Sutton E. Goal achievement in the six months after inpatient rehabilitation for stroke. Disabil Rehabil 2009; 31:880-6. [PMID: 19037772 DOI: 10.1080/09638280802356179] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of the project was to identify characteristics associated with successful re-integration into the community post-inpatient rehabilitation after stroke. A key issue was determining re-integration from the person's perspective, taking into account the person's preferred lifestyle choices. METHOD RESEARCH DESIGN A prospective exploratory follow up study. PARTICIPANTS A consecutive sample of 45 participants discharged from IP rehabilitation following stroke and 23 carers associated with the participants. MEASURES Goal attainment scaling was utilised to determine successful community integration. Factors that may have contributed to goal achievement were measured prior to discharge and at 6 months post-discharge. Scales used include the Functional Independence Measure, Mini Mental test, the CES-D depression scale and a self-efficacy scale, Strategies Used by People to Promote Health. London Handicap Scale scores and Carer Strain Index were collected at 6 months. RESULTS Twenty percent of participants achieved all their goals. Significant correlations were observed between goal achievement score and concurrent measures of physical function, depression and self efficacy at 6 months post-discharge. CONCLUSIONS Stroke survivors who achieved their goals were less likely to be depressed, showed stronger self efficacy beliefs and more positive perceptions of their participation in everyday and community life.
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Affiliation(s)
- Kim Brock
- Rehabilitation Unit, St Vincent's Health, Melbourne, Fitzroy 3065, Victoria, Australia.
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Langhammer B, Lindmark B, Stanghelle JK. The relation between gait velocity and static and dynamic balance in the early rehabilitation of patients with acute stroke. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/14038190600621730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Hammer A, Nilsagård Y, Wallquist M. Balance training in stroke patients – a systematic review of randomized, controlled trials. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/14038190701757656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Langhammer B, Stanghelle JK, Lindmark B. Exercise and health-related quality of life during the first year following acute stroke. A randomized controlled trial. Brain Inj 2009; 22:135-45. [DOI: 10.1080/02699050801895423] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Langhammer B, Stanghelle JK, Lindmark B. An evaluation of two different exercise regimes during the first year following stroke: a randomised controlled trial. Physiother Theory Pract 2009; 25:55-68. [PMID: 19212897 DOI: 10.1080/09593980802686938] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The purpose of this randomised controlled trial was to evaluate the effects of two different exercise approaches during the first 12 months post stroke on Instrumental Activities of Daily Living (IADL), motor function, gait performance, balance, grip strength, and muscle tone. This study is a double-blind longitudinal randomised trial of first-time-ever stroke patients. Seventy-five patients were included: 35 in an intervention group and 40 in a self-initiated exercise group. After discharge from acute rehabilitation, patients assigned in the intervention group had physiotherapy for a minimum amount of 80 hours during the first year. Patients in the self-initiated exercise group were not recommended any specific therapy besides treatment when needed. Main outcome measures were Instrumental Activities of Daily Living according to Fillenbaum, Motor Assessment Scale, 6-Minute Walk Test, Berg Balance Scale, Timed Up-and-Go Test, grip strength, Modified Ashworth Scale, and pulse monitoring. The patients were tested on admission, at discharge, and after 3, 6, and 12 months post stroke by an experienced investigator, blinded to group assignment. Twelve months post stroke showed higher levels of independence in all items of the Instrumental Activities of Daily Living Test and improvements in the results of Motor Assessment Scale, 6-Minute Walk Test, Berg Balance Scale, Timed Up-and-Go, and grip strength in both groups. Only a few significant differences were seen between groups, and they were in favour of the self-initiated exercise group (e.g., ability to use the telephone independently). Attending examination sessions following each intervention phase appeared to be strong motivators for training, irrespective of group allocation.
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Affiliation(s)
- Birgitta Langhammer
- Faculty of Health, Physiotherapy Programme, Oslo University College, St Olavspl, Oslo 4, Norway.
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