Marco Y. C. Pang

A Community-Based Fitness and Mobility Exercise Program for Older Adults with Chronic Stroke: A Randomized, Controlled Trial

Objectives: To examine the effects of a community‐based group exercise program for older individuals with chronic stroke.

The use of aerobic exercise training in improving aerobic capacity in individuals with stroke: a meta-analysis

Objective: To determine whether aerobic exercise improves aerobic capacity in individuals with stroke. Design: A systematic review of randomized controlled trials. Databases searched: MEDLINE, CINAHL, EMBASE, Cochrane Database of Systematic Reviews and Physiotherapy Evidence Database were searched. Inclusion criteria: Design: randomized controlled trials (RCTs). Participants: individuals with stroke. Interventions: aerobic exercise training aimed at improving aerobic capacity. Outcomes: Primary outcomes: aerobic capacity (peak oxygen consumption (VO2), peak workload). Secondary outcomes: walking velocity, walking endurance. Data analysis: The methodological quality was assessed by the PEDro scale. Meta-analyses were performed for all primary and secondary outcomes. Results: Nine articles (seven RCTs) were identified. The exercise intensity ranged from 50% to 80% heart rate reserve. Exercise duration was 20–40 min for 3–5 days a week. The total number of subjects included in the studies was 480. All studies reported positive effects on aerobic capacity, regardless of the stage of stroke recovery. Meta-analysis revealed a significant homogeneous standardized effect size (SES) in favour of aerobic exercise to improve peak VO2 (SES 0.42; 95% confidence interval (CI) 0.15–0.69; P=0.001) and peak workload (SES 0.50; 95% CI 0.26–0.73; P<0.001). There was also a significant homogeneous SES in favour of aerobic training to improve walking velocity (SES 0.26; 95% CI 0.05–0.48; P=0.008) and walking endurance (SES 0.30; 95% CI 0.06–0.55; P=0.008). Conclusions: There is good evidence that aerobic exercise is beneficial for improving aerobic capacity in people with mild and moderate stroke. Aerobic exercise should be an important component of stroke rehabilitation.

The initiation of the swing phase in human infant stepping: importance of hip position and leg loading

1 Hip extension and low load in the extensor muscles are important sensory signals that allow a decerebrate or spinal cat to advance from the stance phase to the swing phase during walking. We tested whether the same sensory information controlled the phases of stepping in human infants. 2 Twenty‐two infants between the ages of 5 and 12 months were studied during supported stepping on a treadmill. Forces exerted by the lower limbs, surface electromyography (EMG) from muscles, and the right hip angle were recorded. The whole experimental session was videotaped. 3 The hip position and the amount of load experienced by the right limb were manipulated during stepping by changing the position of the foot during the stance phase or by applying manual pressure on the pelvic crest. Disturbances with different combinations of hip position and load were used. 4 The stance phase was prolonged and the swing phase delayed when the hip was flexed and the load on the limb was high. In contrast, stance phase was shortened and swing advanced when the hip was extended and the load was low. The results were remarkably similar to those in reduced preparations of the cat. They thus suggest that the behaviour of the brainstem and spinal circuitry for walking may be similar between human infants and cats. 5 There was an inverse relationship between hip position and load at the time of swing initiation, indicating the two factors combine to regulate the transition.

Fear of falling is independently associated with recurrent falls in patients with Parkinson’s disease: a 1-year prospective study

The present study aimed to examine whether fear of falling (FoF) could independently predict recurrent falls in people with Parkinson’s disease (PD). Seventy patients with PD completed the study. Thirty-two patients had fallen at least once in the previous 12xa0months. Most of patients with PD had moderate disease severity (Hoehn and Yahr stage III). FoF was assessed by the activities-specific balance confidence (ABC) scale. PD specific motor and balance impairment was determined by Unified PD rating scale (UPDRS). Functional mobility was measured by timed-up-and-go (TUG) test. All patients were followed for 12xa0months by phone interview to register monthly fall incidence. Results of stepwise discriminant analysis showed that after adjusting for the fall history (Fxa0=xa032.57, Pxa0<xa00.001) and UPDRS motor score (Fxa0=xa025.23, Pxa0<xa00.001), ABC score (Fxa0=xa018.84, Pxa0<xa00.001) remained as a significant predictor of recurrent falls. We further established that a cut-off ABC score of 69 (i.e. 0–100, 0 indicates no confidence and 100 indicates full confidence) demonstrated the best sensitivity (93%) in predicting future falls in PD patients. The results indicate that those with an ABC score <69 at baseline had significantly higher risk of sustaining recurrent falls in the next 12xa0months. Findings of the present study highlight the importance of considering FoF during fall risk assessment in patients with PD.

The effects of whole body vibration therapy on bone mineral density and leg muscle strength in older adults: a systematic review and meta-analysis:

Objective: A systematic review and meta-analysis of randomized controlled trials was undertaken to determine whether whole body vibration improves bone mineral density and leg muscle strength in older adults. Data sources: Sources included MEDLINE, CINAHL, EMBASE, PEDro, PubMed, Science Citation Index and the reference list of each eligible article. Review methods: Article search and selection was performed independently by two researchers. The methodological quality of each selected article was rated by the PEDro scale. Results: Thirteen randomized trials (18 articles) totalling 896 subjects fulfilled the selection criteria. Four were considered to have good or excellent methodological quality and the rest were rated as fair. Meta-analyses revealed that whole body vibration has no significant effect on hip or lumbar spine bone mineral density in older women when compared with no intervention or active exercise (Pu2009>u20090.05). Whole body vibration, however, had a significant treatment effect on knee extension dynamic strength (standardized mean differenceu2009=u20090.63, Pu2009=u20090.006), leg extension isometric strength (standardized mean differenceu2009=u20090.57, Pu2009=u20090.003), and functional measures of leg muscle strength such as jumping height (standardized mean differenceu2009=u20090.51, Pu2009=u20090.010) and performance in sit-to-stand (standardized mean differenceu2009=u20090.72, Pu2009<u20090.001) among older adults compared with no intervention. Conclusion: Whole body vibration is beneficial for enhancing leg muscle strength among older adults. However, the review suggests that whole body vibration has no overall treatment effect on bone mineral density in older women. No randomized trial has examined the effects of whole body vibration on bone mineral density in older men.

Determinants of Satisfaction With Community Reintegration in Older Adults With Chronic Stroke: Role of Balance Self-Efficacy

Background and Purposen Many people with stroke have a low level of satisfaction with community reintegration. Although previous studies focused on the effect of physical factors on community reintegration, the effect of psychological factors, such as balance self-efficacy, has been ignored. The purpose of this study was to determine the contribution of balance self-efficacy to satisfaction with community reintegration in older adults with chronic stroke. n Subjectsn A sample of 63 community-dwelling older adults (50 years of age or older) with chronic stroke (onset of 1 year or more) participated in this study. n Methodsn This study involved a secondary analysis of data collected from a stroke exercise clinical trial. Satisfaction with community reintegration was measured with the Reintegration to Normal Living (RNL) Index, and balance self-efficacy was measured with the Activities-specific Balance Confidence (ABC) Scale. n Resultsn Bivariate correlation analyses showed that the RNL Index scores were moderately correlated with the ABC Scale scores. In a multiple regression analysis, after adjusting for age, sex, depression, and other impairments after stroke, balance self-efficacy remained independently associated with the RNL Index scores, accounting for 6.5% of the variance in the RNL Index scores. n Discussion and Conclusionn Balance self-efficacy is an independent predictor of satisfaction with community reintegration in older adults with chronic stroke. Improving balance self-efficacy may be instrumental in enhancing community reintegration in this population.

The effect of whole body vibration on balance, mobility and falls in older adults: A systematic review and meta-analysis

This systematic review aimed to examine the effect of WBV on balance, mobility and falls among older adults. The databases used included MEDLINE, the Excerpta Medica database, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library Databases of Systematic Reviews, Physiotherapy Evidence Database (PEDro), PubMed, and Science Citation Index (last search in October 2011). Randomized controlled trials that investigated the effect of WBV on balance, mobility or falls in older adults were included in this review. The PEDro score was used to examine the methodological quality of the selected studies. The effect of WBV on balance, mobility and fall-related outcomes were extracted. The data extraction and rating were performed by a researcher and the results were confirmed by the principal investigator. Meta-analysis was done if 3 or more studies measured the same outcome of interest. Among 920 articles screened, fifteen articles (thirteen trials) satisfied the criteria and were included in this review. Methodological quality was good for six of the studies (PEDro score=6-7). Meta-analysis revealed that WBV has a significant treatment effect in Tinetti Total Score (p<0.001), Tinetti Body Balance Score (p=0.010) and Timed-Up-and-Go test (p=0.004). No significant improvement was noted in Tinetti Gait Score after WBV training (p=0.120). The effect of WBV on other balance/mobility outcomes and fall rate remains inconclusive. To conclude, WBV may be effective in improving relatively basic balance ability and mobility among older adults, particularly frailer ones. More good-quality WBV trials are required.

Reduced hip bone mineral density is related to physical fitness and leg lean mass in ambulatory individuals with chronic stroke

Following a stroke, the reduced level of physical activity and functional use of the paretic leg may lead to bone loss and muscle atrophy. These factors and the high incidence of falls may contribute to hip fractures in the stroke population. This study was the first to examine total proximal femur bone mineral content (BMC) and bone mineral density (BMD) and their relationship to stroke-specific impairments in ambulatory individuals with chronic stroke (onset >1xa0year). We utilized dual-energy X-ray absorptiometry (DXA) to acquire proximal femur and total body scans on 58 (23 women) community-dwelling individuals with chronic stroke. We reported total proximal femur BMC (g) and BMD (g/cm2) derived from the proximal femur scans, and lean mass (g) and fat mass (g) for each leg derived from the total body scans. Each subject was evaluated for ambulatory capacity (Six-Minute Walk Test), knee extension strength (hand-held dynamometry), physical fitness [maximal oxygen uptake (VO2max)] and spasticity (Modified Ashworth Scale). Results showed that the paretic leg had significantly lower proximal femur BMD, lean mass and percent lean mass, but higher fat mass than the non-paretic leg for both men and women. Proximal femur BMD of the paretic leg was significantly related to ambulatory capacity ( r =0.33, P =0.011), muscle strength ( r =0.39, P =0.002), physical fitness ( r =0.57, P <0.001), but not related to spasticity ( r =−0.23, P =0.080). Multiple regression analysis showed that lean mass in the paretic leg was a major predictor ( r 2=0.371, P <0.001) of the paretic proximal femur BMD. VO2max was a significant predictor of both paretic proximal femur BMD ( r 2=0.325, P <0.001) and lean mass in the paretic leg ( r 2=0.700, P <0.001). Further study is required to determine whether increasing physical fitness and lean mass are important to improve hip bone health in chronic stroke.

Balance confidence and functional mobility are independently associated with falls in people with Parkinson’s disease

The present study aimed to examine the association of falls with self-perceived balance confidence level, and balance and mobility performance in patients with Parkinson’s disease (PD). Forty-nine healthy subjects and 71 subjects with PD completed the study. Among the PD patients, 33 (46%) were fallers and 38 were non-fallers. All subjects were tested with the activities-specific balance confidence scale (ABC), one-leg-stance test (OLS), and timed-up-and-go test (TUG). Results indicated that PD fallers had significantly lower ABC scores, shorter OLS times and longer times to complete TUG than PD non-fallers (Pxa0<xa00.05). Having a high ABC score (>80) was significantly associated with a lower fall risk, after adjusting for age, gender, and duration of PD, and for depression [odds ratio (OR)xa0=xa00.06, Pxa0=xa00.020]. For performance-based measures of balance and mobility, a longer TUG time (≥16xa0s) was independently associated with increased risk of falling after controlling for relevant factors (ORxa0=xa03.86, Pxa0=xa00.043); OLS time, however, was not significantly associated with falls. A lower self-perceived balance confidence level and a prolonged time to complete TUG were associated with increased risk of falling in patients with PD. Interventions to improve these modifiable risk factors could be useful in reducing future falls in the PD population and will require further study.

Using Aerobic Exercise to Improve Health Outcomes and Quality of Life in Stroke: Evidence-Based Exercise Prescription Recommendations

Background: Stroke patients often suffer from poor cardiovascular health and deficits in physical, psychosocial and cognitive functioning. Aerobic exercise training may be a viable treatment approach to address these health issues. The objective of this systematic review was to determine the effects of aerobic exercise on various indicators of health, functioning and quality of life in stroke patients. It was hypothesized that the systematic review would reveal compelling support for the effectiveness of aerobic exercise in stroke patients, such that detailed evidence-based exercise prescription recommendations could be derived. Methods: Major electronic databases were searched systematically to identify randomized controlled studies that examined the effects of aerobic exercise in stroke patients (last search performed in January 2012). The methodological quality of each study was evaluated using the PEDro scale (9–10 = excellent; 6–8 = good; 4–5 = fair; <4 = poor). Based on the methodological quality and sample size used, the level of evidence was determined for each study (level 1: PEDro ≥6 and sample size >50; level 2: PEDro ≤5 or sample size ≤50). Meta-analysis was performed on a given outcome when appropriate. Results: Twenty-five trials fulfilled the selection criteria, of which 8 were level 1 studies. Treadmill and cycle ergometer were the two most popular modalities used to provide aerobic training. The most commonly adopted exercise session duration and frequency was 21–40 min and 3–5 days per week, respectively. The duration of the training programme varied, ranging from 3 weeks to 6 months. Over 60% of the trials used a high training intensity [60–80% heart rate reserve (HRR)]. Meta-analysis showed a significant effect on peak oxygen consumption (p < 0.001), peak workload (p < 0.001), maximal gait speed (p = 0.003) and walking endurance (p < 0.001) in favour of aerobic exercise. Meta-analysis revealed no significant effect on self-selected gait speed, Berg balance score and Functional Independence Measure score. The efficacy of aerobic exercise in improving other health outcomes in physical, psychosocial and cognitive domains as well as quality of life was inconclusive. The health risk associated with engaging in such exercise is small. Conclusions: There is strong evidence that aerobic exercise (40–50% HRR progressing to 60–80%) conducted 20–40 min and 3–5 days per week is beneficial for enhancing aerobic fitness, walking speed and walking endurance in people who have had mild to moderate stroke and are deemed to have low cardiovascular risk with exercise after proper screening assessments (grade A recommendation). The effects of aerobic exercise on other health outcomes require further study.