Catherine M. Dean

Task-Related Training Improves Performance of Seated Reaching Tasks After Stroke A Randomized Controlled Trial

BACKGROUND AND PURPOSE After stroke, the ability to balance in sitting is critical to independence. Although impairments in sitting balance are common, little is known about the effectiveness of rehabilitation strategies designed to improve it. The purpose of this randomized placebo-controlled study was to evaluate the effect of a 2-week task-related training program aimed at increasing distance reached and the contribution of the affected lower leg to support and balance. METHODS Twenty subjects at least 1 year after stroke were randomized into an experimental or control group. The experimental group participated in a standardized training program involving practice of reaching beyond arms length. The control group received sham training involving completion of cognitive-manipulative tasks within arms length. Performance of reaching in sitting was measured before and after training using electromyography, videotaping, and two force plates. Variables tested were movement time, distance reached, vertical ground reaction forces through the feet, and muscle activity. Subjects were also tested on sit-to-stand, walking, and cognitive tasks. Nineteen subjects completed the study. RESULTS After training, experimental subjects were able to reach faster and further, increase load through the affected foot, and increase activation of affected leg muscles compared with the control group (P < .01). The experimental group also improved in sit-to-stand. The control group did not improve in reaching or sit-to-stand. Neither group improved in walking. CONCLUSIONS This study provides strong evidence of the efficacy of task-related motor training in improving the ability to balance during seated reaching activities after stroke.

A treadmill and overground walking program improves walking in persons residing in the community after stroke: A placebo-controlled, randomized trial

OBJECTIVE To evaluate the effectiveness of a treadmill and overground walking program in reducing the disability and handicap associated with poor walking performance after stroke. DESIGN Randomized, placebo-controlled clinical trial with a 3-month follow-up. SETTING General community. PARTICIPANTS A volunteer sample of 29 ambulatory individuals (less 2 dropouts) who were living in the community after having suffered a stroke more than 6 months previously. INTERVENTIONS The experimental group participated in a 30-minute treadmill and overground walking program, 3 times a week for 4 weeks. The control group received a placebo consisting of a low-intensity, home exercise program and regular telephone contact. MAIN OUTCOME MEASURES Walking speed (over 10 m), walking capacity (distance over 6 min), and handicap (stroke-adapted 30-item version of the Sickness Impact Profile) measured by a blinded assessor. RESULTS The 4-week treadmill and overground walking program significantly increased walking speed (P=.02) and walking capacity (P<.001), but did not decrease handicap (P=.85) compared with the placebo program. These gains were largely maintained 3 months after the cessation of training (P</=.05). CONCLUSIONS The treadmill and overground walking program was effective in improving walking in persons residing in the community after stroke. This suggests that the routine provision of accessible, long-term, community-based walking programs would be beneficial in reducing disability after stroke.

Walking speed over 10 metres overestimates locomotor capacity after stroke

Objective: To examine 10-m comfortable walking speed and 6-minute distance in healthy individuals and individuals after stroke and to assess the level of disability associated with poor walking endurance after stroke. Design: Descriptive study in which comfortable walking speed over 10 m and distance covered in 6 minutes (6-minute walk test) were compared between healthy subjects and subjects after stroke. Subjects: Twelve healthy subjects and 14 subjects after stroke. Main outcome measures: Walking speed and 6-minute distances were compared between groups. In addition, for each group, actual distance walked in 6 minutes was compared with the distance predicted by the 10-m walking speed test and the distance predicted by normative reference equations. Results: Subjects after stroke had significant reductions in 10-m speed and 6-minute distance compared with healthy subjects (p < 0.05). Subjects after stroke were not able to maintain their comfortable walking speed for 6 minutes, whereas healthy subjects walked in excess of their comfortable speed for 6 minutes. The average distance walked in 6 minutes by individuals after stroke was only 49.8 ± 23.9% of the distance predicted for healthy individuals with similar physical characteristics. Conclusion: In our subjects after stroke, walking speed over a short distance overestimated the distance walked in 6 minutes. Both walking speed and endurance need to be measured and trained during rehabilitation.

Functional strength training in cerebral palsy: a pilot study of a group circuit training class for children aged 4–8 years

Objective: To determine the effects of intensive task-specific strength training on lower limb strength and functional performance in children with cerebral palsy. Design: A nonrandomized ABA trial. Setting: Sydney school. Subjects: Eight children with cerebral palsy, aged 4–8 years, seven with diagnosis of spastic diplegia, one of spastic/ataxic quadriplegia. Intervention: Four weeks of after-school exercise class, conducted for one hour twice weekly as group circuit training. Each work station was set up for intensive repetitive practice of an exercise. Children moved between stations, practising functionally based exercises including treadmill walking, step-ups, sit-to-stands and leg presses. Main outcome measures: Baseline test obtained two weeks before training, a pre-test immediately before and a post-test following training, with follow-up eight weeks later. Lower limb muscle strength was tested by dynamometry and Lateral Step-up Test; functional performance by Motor Assessment Scale (Sit-to-Stand), minimum chair height test, timed 10-m test, and 2-minute walk test. Results: Isometric strength improved pre- to post-training by a mean of 47% (SD 16) and functional strength, on Lateral Step-up Test, by 150% (SD 15). Children walked faster over 10 m, with longer strides, improvements of 22% and 38% respectively. Sit-to-stand performance had improved, with a reduction of seat height from 27 (SD 15) to 17 (SD 11) cm. Eight weeks following cessation of training all improvements had been maintained. Conclusions: A short programme of task-specific strengthening exercise and training for children with cerebral palsy, run as a group circuit class, resulted in improved strength and functional performance that was maintained over time.

Physiotherapy in stroke rehabilitation: Bases for Australian physiotherapists' choice of treatment

In a survey of Swedish physiotherapists working in neurology, the treatment of individuals following stroke was found to be essentially praxis-oriented (Nilsson and Nordholm, 1992). The present study replicated the Swedish survey in order to compare the responses of Australian physiotherapists with those of their Swedish colleagues. The questionnaire, designed to establish choice of treatment, factors influencing and theoretical bases for the choice of treatment, and attitudes towards new methods, was sent to the 331 members of the Neurology Special Interest Group of the Australian Physiotherapy Association. The response rate was 72%. Respondents viewed experience working with patients as the most important factor influencing current choice of treatment. As in the Swedish study, although the respondents were able to describe their treatment choices, they had difficulty explaining the underlying theoretical basis for their choice. Difficulty providing a scientific and rational explanation for intervention ...

Motor assessment scale scores as a measure of rehabilitation outcome following stroke.

The purpose of this study was to investigate the outcome of rehabilitation following cerebrovascular accident (CVA) in one Sydney unit. This unit has implemented a philosophy of training based on a motor learning model for rehabilitation proposed by Carr and Shepherd (1987a and b). The proposed motor learning model stresses the need for task and context specific training of everyday actions. Data, including patient characteristics and Motor Assessment Scale (MAS) scores, were collected through a retrospective audit of all patients diagnosed as having a CVA and discharged from the unit during 1989. The major finding of this study was that, following rehabilitation within a multi-disciplinary program, patients were able to improve their motor performance as demonstrated by changes in MAS scores. The measurement of outcome of rehabilitation for this unit has contributed to quality assurance by identifying motor tasks that warrant further emphasis in training in order to improve upon the reported outcome of rehabilitation.

Sitting balance I: trunk–arm coordination and the contribution of the lower limbs during self-paced reaching in sitting

The effects of reach distance and type of task on the functional relationship between the trunk, upper limb segments and the lower limbs during self-paced reaching in sitting were examined. Two-dimensional kinematic, kinetic and electromyography (EMG) data were collected as six healthy subjects reached forward under three distance (60, 100, 140% arms length) and two task (reaching to press a switch, reaching to grasp a glass) conditions. The results demonstrate that type of task affected primarily the temporal aspects of coordination, with the grasp task taking consistently longer than the press task. In contrast, reach distance affected both the spatio-temporal aspects of coordination between the trunk and arm segments and the active contribution of the lower limbs. As reach distance increased, the magnitude of trunk and upper-arm segmental motion increased, whereas forearm segmental motion decreased. However, at each reach distance the path of the hand was relatively straight and there was remarkable consistency in the relationship between trunk and arm segments both within and between subjects suggesting that despite the presence of redundant degrees of freedom, the individual uses a parsimonious coordinative pattern. The vertical ground reaction force (GRF) and EMG data demonstrated that the lower limbs actively contributed to support the body mass when the object was located at 140% arms length.

Exercise to enhance mobility and prevent falls after stroke: the community stroke club randomized trial

Background. Exercise interventions can enhance mobility after stroke as well as prevent falls in elderly persons. Objective. Investigate whether an exercise intervention can enhance mobility, prevent falls, and increase physical activity among community-dwelling people after stroke. Method. A randomized trial with blinding of physical outcome assessment was conducted through local stroke clubs. Both groups, on average 5.9 years poststroke, received exercise classes, advice, and a home program for 12 months. The experimental group (EG) program (n = 76) aimed to improve walking, prevent falls and increase physical activity. The control group (CG) program (n = 75) aimed to improve upper-limb and cognitive functions. The primary outcomes were walking capacity, walking speed measured before and after the intervention, and fall rates monitored monthly. Results. At 12 months, the EG walked 34 m further in 6 minutes (95% confidence interval [CI] = 19-50; P < .001) and 0.07 m/s faster over 10 m (95% CI = 0.01-0.14; P = .03) than the CG. The EG had 129 falls, and the CG had 133. There were no differences in proportion of fallers (relative risk = 1.22; 95% CI = 0.91-1.62; P = .19) or the rate of falls between groups (incidence rate ratio = 0.96; 95% CI = 0.59-1.51; P = .88). Conclusion. The experimental intervention delivered through stroke clubs enhanced aspects of mobility but had no effect on falls.

Randomized Trial of Treadmill Walking With Body Weight Support to Establish Walking in Subacute Stroke The MOBILISE Trial

Background and Purpose— The main objective of this randomized trial was to determine whether treadmill walking with body weight support was effective at establishing independent walking more often and earlier than current physiotherapy intervention for nonambulatory stroke patients. Methods— A randomized trial with concealed allocation, blinded assessment, and intention-to-treat analysis was conducted. One hundred twenty-six stroke patients who were unable to walk were recruited and randomly allocated to an experimental or a control group within 4 weeks of stroke. The experimental group undertook up to 30 minutes per day of treadmill walking with body weight support via an overhead harness whereas the control group undertook up to 30 minutes of overground walking. The primary outcome was the proportion of participants achieving independent walking within 6 months. Results— Kaplan–Meier estimates of the proportion of experimental participants who achieved independent walking were 37% compared with 26% of the control group at 1 month, 66% compared with 55% at 2 months, and 71% compared with 60% at 6 months (P=0.13). The experimental group walked 2 weeks earlier, with a median time to independent walking of 5 weeks compared to 7 weeks for the control group. In addition, 14% (95% CI, −1–28) more of the experimental group were discharged home. Conclusions— Treadmill walking with body weight support is feasible, safe, and tends to result in more people walking independently and earlier after stroke. Trial Registration— NNClinicalTrial.gov (NCT00167531).

Mechanically assisted walking with body weight support results in more independent walking than assisted overground walking in non-ambulatory patients early after stroke: a systematic review

QUESTION Does mechanically assisted walking with body weight support result in more independent walking and is it detrimental to walking speed or capacity in non-ambulatory patients early after stroke? DESIGN Systematic review with meta-analysis of randomised trials. PARTICIPANTS Non-ambulatory adult patients undergoing inpatient rehabilitation up to 3 months after stroke. INTERVENTION Mechanically assisted walking (eg, treadmill, electromechanical gait trainer, robotic device, servo-motor) with body weight support (eg, harness with or without handrail, but not handrail alone) versus assisted overground walking of longer than 15 min duration. OUTCOME MEASURES The primary outcome was the proportion of participants achieving independent walking. Secondary outcomes were walking speed measured as m/s during the 10-m Walk Test and walking capacity measured as distance in m during the 6-min Walk Test. RESULTS Six studies comprising 549 participants were identified and included in meta-analyses. Mechanically assisted walking with body weight support resulted in more people walking independently at 4 weeks (RD 0.23, 95% CI 0.15 to 0.30) and at 6 months (RD 0.23, 95% CI 0.07 to 0.39), faster walking at 6 months (MD 0.12 m/s, 95% CI 0.02 to 0.21), and further walking at 6 months (MD 55 m, 95% CI 15 to 96) than assisted overground walking. CONCLUSION Mechanically assisted walking with body weight support is more effective than overground walking at increasing independent walking in non-ambulatory patients early after stroke. Furthermore, it is not detrimental to walking speed or capacity and clinicians should therefore be confident about implementing this intervention.