Lucas R. Nascimento

Treadmill training is effective for ambulatory adults with stroke: a systematic review

QUESTION Does mechanically assisted walking increase walking speed or distance in ambulatory people with stroke compared with no intervention/non-walking intervention, or with overground walking? DESIGN Systematic review with meta-analysis of randomised trials. PARTICIPANTS Ambulatory adults with stroke. INTERVENTION Mechanically assisted walking (treadmill or gait trainer) without body weight support. OUTCOME MEASURES Walking speed measured in m/s during the 10-m Walk Test and walking distance measured in m during the 6-min Walk Test. RESULTS Nine studies of treadmill training comprising 977 participants were included. Treadmill training resulted in faster walking than no intervention/non-walking intervention immediately after the intervention period (MD 0.14m/s, 95% CI 0.09 to 0.19) and this was maintained beyond the intervention period (MD -0.12m/s, 95% CI 0.08 to 0.17). It also resulted in greater walking distance immediately after the intervention period (MD 40m, 95% CI 27 to 53) and this was also maintained beyond the intervention period (MD 40m, 95% CI 24 to 55). There was no immediate, statistically significant difference between treadmill training and overground training in terms of walking speed (MD 0.05m/s, 95% CI 0.12 to 0.21) or distance (MD -6m, 95% CI -45 to 33). CONCLUSION This systematic review provides evidence that, for people with stroke who can walk, treadmill training without body weight support results in faster walking speed and greater distance than no intervention/ non-walking intervention and the benefit is maintained beyond the training period.

The effects of walking sticks on gait kinematics and kinetics with chronic stroke survivors

BACKGROUND There are robust clinical paradigms against the prescription of walking sticks for people with stroke. However, there is little information on the biomechanics of gait with and without these devices to guide clinical practice. Therefore, this study investigated how the use of walking sticks (canes or crutches) affected both the kinematics and kinetics of gait in people with chronic stroke after their walking had stabilized. METHODS Nineteen people with chronic stroke walked at both comfortable and fast speeds. A 3-D motion analysis system and one force platform were used to obtain kinematic and kinetic data of the paretic lower limb during four conditions: With and without walking sticks, and at comfortable and fast speeds. Outcomes included linear kinematics (walking speeds) and angular kinematics (maximum joint angles), power, and work of the paretic hip, knee and ankle joints in the saggital plane. FINDINGS The use of walking sticks resulted in increases in speed during both fast (P<0.001) and comfortable (P=0.001) walking, but did not result in changes in maximum joint angles. This also led to increases in ankle plantar flexion (P<0.01), knee extension (P<0.01), and hip flexion (P<0.001) power generation, but did not result in changes in work. There were no greater changes as a result of using walking sticks during fast versus comfortable walking for any outcome. INTERPRETATIN: The outcomes with the use of walking sticks were beneficial, which suggests that the prescription of these devices is not detrimental to walking that was stabilized in people with stroke.

Walking training with cueing of cadence improves walking speed and stride length after stroke more than walking training alone: a systematic review

QUESTION After stroke, is walking training with cueing of cadence superior to walking training alone in improving walking speed, stride length, cadence and symmetry? DESIGN Systematic review with meta-analysis of randomised or controlled trials. PARTICIPANTS Adults who have had a stroke. INTERVENTION Walking training with cueing of cadence. OUTCOME MEASURES Four walking outcomes were of interest: walking speed, stride length, cadence and symmetry. RESULTS This review included seven trials involving 211 participants. Because one trial caused substantial statistical heterogeneity, meta-analyses were conducted with and without this trial. Walking training with cueing of cadence improved walking speed by 0.23 m/s (95% CI 0.18 to 0.27, I(2)=0%), stride length by 0.21 m (95% CI 0.14 to 0.28, I(2)=18%), cadence by 19 steps/minute (95% CI 14 to 23, I(2)=40%), and symmetry by 15% (95% CI 3 to 26, random effects) more than walking training alone. CONCLUSIONS This review provides evidence that walking training with cueing of cadence improves walking speed and stride length more than walking training alone. It may also produce benefits in terms of cadence and symmetry of walking. The evidence appears strong enough to recommend the addition of 30 minutes of cueing of cadence to walking training, four times a week for 4 weeks, in order to improve walking in moderately disabled individuals with stroke. REVIEW REGISTRATION PROSPERO (CRD42013005873).

Cyclical electrical stimulation increases strength and improves activity after stroke: a systematic review

QUESTION Does electrical stimulation increase strength after stroke and are any benefits maintained beyond the intervention period or carried over to activity? DESIGN Systematic review with meta-analysis of randomised or controlled trials. PARTICIPANTS Adults who have had a stroke. INTERVENTION Cyclical electrical stimulation applied in order to increase muscle strength. OUTCOME MEASURES Strength measures had to be representative of maximum voluntary contraction and were obtained as continuous measures of force or torque, or ordinal measures such as manual muscle tests. Activity was measured using direct measures of performance that produced continuous or ordinal data, or with scales that produced ordinal data. RESULTS Sixteen trials representing 17 relevant comparisons were included in this systematic review. Effect sizes were calculated as standardised mean differences because various muscles were studied and different outcome measures were used. Overall, electrical stimulation increased strength by a standardised mean difference (SMD) of 0.47 (95% CI 0.26 to 0.68) and this effect was maintained beyond the intervention period (SMD 0.33, 95% CI 0.07 to 0.60). Electrical stimulation also improved activity (SMD 0.30, 95% CI 0.05 to 0.56) and this effect was also maintained beyond the intervention period (SMD 0.38, 95% CI 0.09 to 0.66). CONCLUSION Cyclical electrical stimulation increases strength and improves activity after stroke. These benefits were maintained beyond the intervention period with a small-to-moderate effect size. The sustained effect on activity suggests that the benefits were incorporated into daily life. Review registration: PROSPERO (CRD42013003895).

Walking training associated with virtual reality-based training increases walking speed of individuals with chronic stroke: systematic review with meta-analysis

OBJECTIVE: To systematically review the available evidence on the efficacy of walking training associated with virtual reality-based training in patients with stroke. The specific questions were: Is walking training associated with virtual reality-based training effective in increasing walking speed after stroke? Is this type of intervention more effective in increasing walking speed, than non-virtual reality-based walking interventions? METHOD: A systematic review with meta-analysis of randomized clinical trials was conducted. Participants were adults with chronic stroke and the experimental intervention was walking training associated with virtual reality-based training to increase walking speed. The outcome data regarding walking speed were extracted from the eligible trials and were combined using a meta-analysis approach. RESULTS: Seven trials representing eight comparisons were included in this systematic review. Overall, the virtual reality-based training increased walking speed by 0.17 m/s (IC 95% 0.08 to 0.26), compared with placebo/nothing or non-walking interventions. In addition, the virtual reality-based training increased walking speed by 0.15 m/s (IC 95% 0.05 to 0.24), compared with non-virtual reality walking interventions. CONCLUSIONS: This review provided evidence that walking training associated with virtual reality-based training was effective in increasing walking speed after stroke, and resulted in better results than non-virtual reality interventions.

Motor Activity Log-Brazil: reliability and relationships with motor impairments in individuals with chronic stroke

UNLABELLED The Motor Activity Log (MAL) assesses the spontaneous use of the most affected upper limb with the amount of use (AOU) and quality of movement (QOM) scales during daily activities in real environments in individuals with chronic stroke. OBJECTIVES This study translated the testing manual into Portuguese and assessed the inter-rater and test-retest reliabilities of the MAL, based upon the Brazilian manual version. METHODS The inter-rater reliability was evaluated by comparing the results of two examiners, and the test-retest reliability was tested by comparing the results of two evaluations, repeated one-week apart with 30 individuals with chronic hemiparesis (55.8±15.1 years). RESULTS The intra-class correlation coefficients (ICCs) for the total scores were adequate for both the inter-rater (0.98 for the AOU and 0.91 for QOM) and test-retest reliabilities (0.99 for both scales). CONCLUSIONS The results suggested that the MAL was reliable to evaluate the spontaneous use of the most affected upper limb after stroke.

Isometric hand grip strength correlated with isokinetic data of the shoulder stabilizers in individuals with chronic stroke

The purpose of this study was to examine the relationships between isometric hand grip (HG) strength and isokinetic strength data of the glenoumeral and scapulothoracic muscles in 12 individuals with chronic hemiparesis due to stroke. Measures of maximal grip strength were obtained on the HG dynamometer Jamar(®). Isokinetic measures of peak torque and work during shoulder rotations and scapular protraction-retraction movements were obtained with the isokinetic dynamometer at a speed of 60°/s. Pearson correlation coefficients between isometric HG and isokinetic strength data ranged between 0.60 and 0.82 for the peak torque and between 0.59 and 0.86 for the isokinetic work. The findings suggested that, in absence of isokinetic dynamometers, isometric HG strength measurements could be clinically used to monitor strength levels of the shoulder stabilizers and to guide load progressions during strengthening interventions for people with chronic hemiparesis.

Respiratory muscle training increases respiratory muscle strength and reduces respiratory complications after stroke: a systematic review.

QUESTION After stroke, does respiratory muscle training increase respiratory muscle strength and/or endurance? Are any benefits carried over to activity and/or participation? Does it reduce respiratory complications? DESIGN Systematic review of randomised or quasi-randomised trials. PARTICIPANTS Adults with respiratory muscle weakness following stroke. INTERVENTION Respiratory muscle training aimed at increasing inspiratory and/or expiratory muscle strength. OUTCOME MEASURES Five outcomes were of interest: respiratory muscle strength, respiratory muscle endurance, activity, participation and respiratory complications. RESULTS Five trials involving 263 participants were included. The mean PEDro score was 6.4 (range 3 to 8), showing moderate methodological quality. Random-effects meta-analyses showed that respiratory muscle training increased maximal inspiratory pressure by 7 cmH2O (95% CI 1 to 14) and maximal expiratory pressure by 13 cmH2O (95% CI 1 to 25); it also decreased the risk of respiratory complications (RR 0.38, 95% CI 0.15 to 0.96) compared with no/sham respiratory intervention. Whether these effects carry over to activity and participation remains uncertain. CONCLUSION This systematic review provided evidence that respiratory muscle training is effective after stroke. Meta-analyses based on five trials indicated that 30minutes of respiratory muscle training, five times per week, for 5 weeks can be expected to increase respiratory muscle strength in very weak individuals after stroke. In addition, respiratory muscle training is expected to reduce the risk of respiratory complications after stroke. Further studies are warranted to investigate whether the benefits are carried over to activity and participation. REGISTRATION PROSPERO (CRD42015020683). [Menezes KKP, Nascimento LR, Ada L, Polese JC, Avelino PR, Teixeira-Salmela LF (2016) Respiratory muscle training increases respiratory muscle strength and reduces respiratory complications after stroke: a systematic review.Journal of Physiotherapy62: 138-144].

Strength deficits of the shoulder complex during isokinetic testing in people with chronic stroke

OBJECTIVES: To examine the strength deficits of the shoulder complex after stroke and to characterize the pattern of weakness according to type of movement and type of isokinetic parameter. METHOD: Twelve chronic stroke survivors and 12 age-matched healthy controls had their shoulder strength measured using a Biodex isokinetic dynamometer. Concentric measures of peak torque and work during shoulder movements were obtained in random order at speeds of 60°/s for both groups and sides. Type of movement was defined as scapulothoracic (protraction and retraction), glenohumeral (shoulder internal and external rotation) or combined (shoulder flexion and extension). Type of isokinetic parameter was defined as maximum (peak torque) or sustained (work). Strength deficits were calculated using the control group as reference. RESULTS: The average strength deficit for the paretic upper limb was 52% for peak torque and 56% for work. Decreases observed in the non-paretic shoulder were 21% and 22%, respectively. Strength deficit of the scapulothoracic muscles was similar to the glenohumeral muscles, with a mean difference of 6% (95% CI -5 to 17). Ability to sustain torque throughout a given range of motion was decreased as much as the peak torque, with a mean difference of 4% (95% CI -2 to 10). CONCLUSIONS: The findings suggest that people after stroke might benefit from strengthening exercises directed at the paretic scapulothoracic muscles in addition to exercises of arm elevation. Clinicians should also prescribe different exercises to improve the ability to generate force and the ability to sustain the torque during a specific range of motion.

The provision of a cane provides greater benefit to community-dwelling people after stroke with a baseline walking speed between 0.4 and 0.8 metres/second: an experimental study.

OBJECTIVE To investigate the effect of the provision of a cane on walking ability in ambulatory people with chronic stroke. DESIGN Experimental study. SETTING Clinics within the community. PARTICIPANTS Twenty-four people on average 6 years after a stroke, who were not regular users of walking sticks. Participants were categorized as slow (<0.4 metres/second), intermediate (0.4-0.8 metres/second), or fast walkers (>0.8 metres/second) on the basis of their baseline walking ability. EXPERIMENTAL CONDITIONS Walking with and without a cane. MAIN OUTCOME MEASURES Walking ability was measured using the 10-m Walk Test and reported as speed (metres/second), step length (metres), and cadence (steps/minute). RESULTS Overall, the provision of a cane produced no significant change in speed (0.05 metres/second, 95% CI -0.01 to 0.11) or cadence (-3 steps/minute; 95% CI -8 to 3), but a small increase in step length (0.04 metres, 95% CI 0.03 to 0.06). For the intermediate walkers, the cane increased speed by 0.18 metres/second (95% CI 0.11 to 0.24), step length by 0.07 metres (95% CI 0.05 to 0.09), but not cadence. The provision of a cane to the intermediate walkers also produced 0.27 metres/second (95% CI 0.18 to 0.36) more increase in speed compared with the fast walkers, and 0.12 metres/second (95% CI 0.03 to 0.21) more increase compared with the slow walkers. CONCLUSION The provision of a cane produced most benefit to a subgroup of intermediate walkers in a group of community-dwelling people with chronic stroke whose walking had stabilized, without detriment to quality of walking.