Eline Lindeman

Strength training in patients with myotonic dystrophy and hereditary motor and sensory neuropathy: A randomized clinical trial

A randomized clinical trial on the effects of strength training was performed in myotonic dystrophy (MyD) patients and patients with hereditary motor and sensory neuropathy (HMSN). Training and most measurement tools involved the proximal lower extremity muscles. The participants trained 3 times a week for 24 weeks with weights adapted to their force. Strength was evaluated by isokinetically measured knee torque. Fatiguability was assessed by the time an isometric contraction could be sustained. Functional performance was measured by timed motor performance and by questionnaires on functional performance. Serum myoglobin (Mb) levels were determined to detect changes in muscle fiber membrane permeability. The MyD group included 33 participants, and the HMSN group included 29 participants. Within each diagnostic group, patients were individually matched and subsequently randomized for treatment allocation. In the MyD patients, none of the measurement techniques showed any training effect. Neither were there signs of deterioration caused by the training. In the HMSN group, knee torques increased. Timed motor performance did not change, although the questionnaires showed an improvement on items related to upper-leg function. Mb levels did not change significantly as a result of the training. In conclusion, the MyD group showed neither positive nor negative effects of the training protocol, whereas the training produced a moderate increase in strength and leg-related functional performance in the HMSN group.

Predicting improvement in gait after stroke: a longitudinal prospective study.

Background and Purpose— To study the longitudinal relationship of functional change in walking ability and change in time-dependent covariates and to develop a multivariate regression model to predict longitudinal change of walking ability. Methods— A total of 101 acute stroke patients with first-ever ischemic middle cerebral artery strokes was used as the population. Prospective cohort study based on 18 repeated measurements over time during the first poststroke year. Baseline characteristics as well as longitudinal information from functional ambulation categories (FAC), Fugl–Meyer leg score (FM-leg), Motricity index leg score (MI-leg), letter cancellation task (LCT), Fugl-Meyer balance (FM-balance), and timed balance test (TBT) were obtained. Intervention consisted of a basic rehabilitation program with additional arm, leg, or air splint therapy. Main outcome measure constituted change scores on FAC over time. Results— In total, 1532 of the 1717 change scores were available for regression analysis. The regression model showed that TBT change scores were the most important factor in predicting improvement on FAC (&bgr;=0.094; P<0.001) followed by changes scores on FM-leg (&bgr;=0.014; P<0.001) and reduction in LCT omissions (&bgr;=−0.010; P<0.001) and MI leg test (&bgr;=0.001; P<0.001). In addition, time itself was significantly negatively associated with improvement (&bgr;=−0.002; P<0.001). Conclusion— Improvement in standing balance control is more important than improvement in leg strength or synergism to achieve improvement in walking ability, whereas reduction in visuospatial inattention is independently related to improvement of gait. Finally, time itself is an independent covariate that is negatively associated with change on FAC, suggesting that most pronounced improvements occur earlier after stroke.

Effects of exercise training programs on walking competency after stroke - A systematic review

van de Port IGL, Wood-Dauphinee S, Lindeman E, Kwakkel G: Effects of exercise training programs on walking competency after stroke: a systematic review. Am J Phys Med Rehabil 2007;86:935–951. To determine the effectiveness of training programs that focus on lower-limb strengthening, cardiorespiratory fitness, or gait-oriented tasks in improving gait, gait-related activities, and health-related quality of life after stroke. Randomized controlled trials (RCTs) were searched for in the databases of Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, Physiotherapy Evidence Database (PEDro), EMBASE, Database of the Dutch Institute of Allied Health Care, and CINAHL. Databases were systematically searched by two independent researchers. The following inclusion criteria were applied: (1) participants were people with stroke, older than 18 yrs; (2) one of the outcomes focused on gait-related activities; (3) the studies evaluated the effectiveness of therapy programs focusing on lower-limb strengthening, cardiorespiratory fitness, or gait-oriented training; and (4) the study was published in English, German, or Dutch. Studies were collected up to November 2005, and their methodological quality was assessed using the PEDro scale. Studies were pooled and summarized effect sizes were calculated. Best-evidence synthesis was applied if pooling was impossible. Twenty-one RCTs were included, of which five focused on lower-limb strengthening, two on cardiorespiratory fitness training (e.g., cycling exercises), and 14 on gait-oriented training. Median PEDro score was 7. Meta-analysis showed a significant medium effect of gait-oriented training interventions on both gait speed and walking distance, whereas a small, nonsignificant effect size was found on balance. Cardiorespiratory fitness programs had a nonsignificant medium effect size on gait speed. No significant effects were found for programs targeting lower-limb strengthening. In the best-evidence synthesis, strong evidence was found to support cardiorespiratory training for stair-climbing performance. Although functional mobility was positively affected, no evidence was found that activities of daily living, instrumental activities of daily living, or health-related quality of life were significantly affected by gait-oriented training. This review shows that gait-oriented training is effective in improving walking competency after stroke.

Measures used to assess burden among caregivers of stroke patients: a review

Objective: To describe measures used to evaluate the burden of caregiving experienced by caregivers of stroke patients and their clinimetric properties. Design: A review of the literature was conducted to examine burden scales with regard to concept, feasibility, internal consistency, validity, reliability and responsiveness. Results: The literature search resulted in 45 measures of caregiver outcomes, including 16 different measures of caregiver burden. About half of the scales were used only once and were not further described. Nearly all instruments measure the various dimensions of burden (competency, negative feelings, social relations, participation problems, physical and mental health and economic aspects), but not in the same proportions. Most measures showed good internal consistency, and validity was demonstrated for all measures except one. However, not much is known about the reliability and responsiveness of these measures. Conclusions: No measure has proven superiority above others. Future research should focus on comparisons between existing instruments and on their reliability and responsiveness.

Susceptibility to deterioration of mobility long-term after stroke: a prospective cohort study

Background and Purpose— The aim of the present study was to identify clinical determinants able to predict which individuals are susceptible to deterioration of mobility from 1 to 3 years after stroke. Methods— Prospective cohort study of stroke patients consecutively admitted for inpatient rehabilitation. A total of 205 relatively young, first-ever stroke patients were assessed at 1 and 3 years after stroke. Mobility status was determined by the Rivermead Mobility Index (RMI), and decline was defined as a deterioration of ≥2 points on the RMI. Univariate and multivariate logistic regression analyses were performed to identify prognostic factors for mobility decline. The discriminating ability of the model was determined using a receiver operating characteristic curve. Results— A decline in mobility status was found in 21% of the patients. Inactivity and the presence of cognitive problems, fatigue, and depression at 1 year after stroke were significant predictors of mobility decline. The multivariate model showed a good fit (Hosmer–Lemeshow test P>0.05), and discriminating ability was good (area under the curve 0.79). Conclusions— Mobility decline is an essential concern in chronic stroke patients, especially because it might lead to activities of daily living dependence and affects social reintegration. Early recognition of prognostic factors in patients at risk may guide clinicians to apply interventions aimed to prevent deterioration of mobility status in chronic stroke.

Is Fatigue an Independent Factor Associated with Activities of Daily Living, Instrumental Activities of Daily Living and Health-Related Quality of Life in Chronic Stroke?

Background: To determine the longitudinal association of poststroke fatigue with activities of daily living (ADL), instrumental ADL (IADL) and perceived health-related quality of life (HRQoL) and to establish whether this relationship is confounded by other determinants. Methods: A prospective cohort study of stroke patients consecutively admitted for inpatient rehabilitation was conducted. ADL, IADL and HRQoL were assessed in 223 patients at 6, 12 and 36 months after stroke. Fatigue was determined by the Fatigue Severity Scale. Random coefficient analysis was used to analyze the impact of fatigue on ADL, IADL and HRQoL. The association between fatigue and outcome was corrected for potential confounders, i.e. age, gender, comorbidity, executive function, severity of paresis and depression. The covariate was considered to be a confounder if the regression coefficient of fatigue on outcome changed by >15%. Results: Fatigue was significantly related to IADL and HRQoL but not to ADL. The relation between fatigue and IADL was confounded by depression and motor impairment. Depression biased the relation between fatigue and HRQoL, but fatigue remained independently related to HRQoL. Conclusions: Fatigue is longitudinally spuriously associated with IADL and independently with HRQoL. These findings suggest that in examining the impact of poststroke fatigue on outcome, one should control for confounders such as depression.

Rehabilitation of stroke patients needs a family-centred approach

Purpose. To highlight the importance of the spouse in stroke rehabilitation. Stroke not only affects the patients, but also their families, but rehabilitation practice is still primarily focused on the patient only. Method. Analysis of the position of the spouse and possible consequences of stroke for the spouse, based on the literature. Results. Three roles of spouses are described: (i) the role of caregiver, as the spouse often provides extensive and comprehensive care for the patient; (ii) the role of client, as this informal care may lead to physical and emotional strain; and (iii) the role of family member, as the stroke affects the interpersonal relationships within the family system, not least the emotional and sexual relationship between the partners. This analysis provides an understanding of problems experienced by spouses as roles conflict and identifies topics for assessment and interventions directed at the spouse in the acute phase, rehabilitation phase and chronic phase of stroke. Conclusion. We support a family-centred approach in which the strengths and needs of all family members, the patient with stroke included, are considered throughout all phases of the rehabilitation process.

Effects of visual feedback therapy on postural control in bilateral standing after stroke: a systematic review.

OBJECTIVE To establish whether bilateral standing with visual feedback therapy after stroke improves postural control compared with conventional therapy and to evaluate the generalization of the effects of visual feedback therapy on gait and gait-related activities. DESIGN A systematic review. METHODS A computer-aided literature search was performed. Randomized controlled trials and controlled clinical trials, comparing visual feedback therapy with conventional balance treatments were included up to April 2005. The methodological quality of each study was assessed with the the Physiotherapy Evidence Database scale. Depending on existing heterogeneity, studies with a common variable of outcome were pooled by calculating the summary effect-sizes using fixed or random effects models. RESULTS Eight out of 78 studies, presenting 214 subjects, were included for qualitative and quantitative analysis. The methodological quality ranged from 3 to 6 points. The meta-analysis demonstrated non-significant summary effect-sizes in favour of visual feedback therapy for weight distribution and postural sway, as well as balance and gait performance, and gait speed. CONCLUSION The additional value of visual feedback therapy in bilateral standing compared with conventional therapy shows no statistically significant effects on symmetry of weight distribution between paretic and non-paretic leg, postural sway in bilateral standing, gait and gait-related activities. Visual feedback therapy should not be favoured over conventional therapy. The question remains as to exactly how asymmetry in weight distribution while standing is related to balance control in patients with stroke.

Psychosocial Functioning of Spouses of Patients With Stroke From Initial Inpatient Rehabilitation to 3 Years Poststroke: Course and Relations With Coping Strategies

Background and Purpose— Few studies have focused on long-term changes in the caregiving experience after stroke. This study assessed changes in the psychosocial functioning of spouses (burden, depressive symptoms, harmony in the relationship between patient and spouse, and social relations) during the first 3 years after stroke and identified predictors of the course of spouses’ psychosocial functioning based on the characteristics of patients and spouses with special emphasis on coping style. Methods— We examined 211 couples shortly after the patient’s admission to a rehabilitation center, 197 2 months after discharge, 187 1 year poststroke, and 121 3 years poststroke. Burden was assessed using the Caregiver Strain Index, depressive symptoms with the Goldberg Depression Scale, harmony in the relationship with the Interactional Problem Solving Inventory, and social relations with the Social Support List. Multilevel regression analyses were performed. Results— A significant effect of time (P<0.01) was found for all 4 aspects of spouses’ psychosocial functioning. Although burden decreased, harmony in the relationship and social relations also decreased. The depression score showed a nonlinear pattern with an initial decrease but a long-term increase. All outcomes were significantly related to caregiver coping strategies. A total of 15% to 27% of the variance in psychosocial functioning could be explained. Conclusions— Follow-up of spouses of patients with stroke requires not only assessment of burden, but also other aspects of psychosocial functioning like harmony in the relationship, depression, and social relations, because our results show negative long-term consequences of stroke for these aspects of caregiver quality of life.

Spouses' quality of life 1 year after stroke: Prediction at the start of clinical rehabilitation

Background and Purpose: The purpose of this prospective study was to identify early predictors of spouses’ quality of life at 1 year after stroke. Methods: At the start of clinical rehabilitation patient and caregiver characteristics, psychological factors, harmony in the relationship and social support were assessed. One year after stroke, caregiver burden (Caregiver Strain Index), life satisfaction (Life Satisfaction Checklist) and depressive symptoms (Goldberg Depression Scale) were assessed in 187 participants. Multiple regression analyses were performed. Results: About 80% of the spouses reported low quality of life on one or more of the measures; 52% reported depressive symptoms, 54% significant strain and only 50% was satisfied with life as a whole. The regression analysis identified ‘passive coping strategy of the caregiver’ as the most important predictor. ADL dependency was the only baseline patient characteristic significantly related to burden and life satisfaction, but explained just 0–4% of the variance. Conclusions: A large proportion of caregivers perceive impaired quality of life 1 year after stroke. Caregivers at risk should be identified at the start of rehabilitation by means of coping measurement instruments or selected anamneses on coping.