Oona M. Scott

Effectiveness of a community-based low intensity exercise programme for ambulatory stroke survivors

Purpose. To establish the feasibility and effectiveness of a community-based exercise programme for ambulatory patients with stroke discharged from rehabilitation Method. Eighteen participants were recruited 3–12 months after onset of first stroke. Using a time series experimental design, the group completed a baseline period of 4 weeks (A1), a group exercise programme of low-intensity progressive resistive exercise and functional tasks for lower limb muscles (B) and repeat assessment after cessation of exercise (A2). Fitness instructors delivered sessions at Leisure Centres twice weekly for 14 weeks with physiotherapy support and the minimum attendance requirement was 16 sessions. Measures included muscle strength, gait velocity, Berg Balance Scale and Nottingham Extended Activities of Daily Living. Results. Lower limb muscle strength improved after training (ANOVA, p < 0.02). Paretic knee extension strength increased from 43.4 ± 5.9 to 60.4 ± 6.8 Nm after 16 exercise sessions. Walking velocity increased significantly (ANOVA, p < 0.001), from 0.54 ± 0.07 to 0.75 ± 0.08 m/s (t = −3.31, p < 0.01). Balance and everyday function were also significantly improved (p < 0.003). There were marked individual variation in the response to training, and those who completed additional training did not show benefit. Conclusions. This community-based exercise programme was feasible and delivered positive improvements in physical function for participants. Further issues raised for investigation include the individual response to training and the benefits of extended training.

Comparison of biomechanical gait parameters of young children with haemophilia and those of age-matched peers

Summary.  Quality of life for children with haemophilia has improved since the introduction of prophylaxis. The frequency of joint haemorrhages has reduced, but the consequences of reduced bleeding on the biomechanical parameters of walking are not well understood. This study explored the differences in sagittal plane biomechanics of walking between a control group (Group 1) of normal age‐matched children and children with haemophilia (Group 2) with a target ankle joint. A motion capture system and two force platforms were used to collect sagittal plane kinematic, kinetic and temporal–spatial data during walking of 14 age‐matched normal children and 14 children with haemophilia aged 7–13 years. Group differences in maximum and minimum flexion/extension angles and moments of the hip, knee and ankle joints, ground reaction forces and temporal–spatial gait cycle parameters were analysed using one‐way anova. Significant changes (P < 0.05) in kinematic and kinetic parameters but not temporal–spatial parameters were found in children with haemophilia; greater flexion angles and external moments of force at the knee, greater ankle plantarflexion external moments and lower hip flexion external moments. These results suggest that early biomechanical changes are present in young haemophilic children with a history of a target ankle joint and imply that lower limb joint function is more impaired than current clinical evaluations indicate. Protocols and quantitative data on the biomechanical gait pattern of children with haemophilia reported in this study provide a baseline to evaluate lower limb joint function and clinical progression.

Low intensity strength training for ambulatory stroke patients.

Purpose. To investigate feasibility and effectiveness of an individually-directed, group strength-training programme on knee muscle strength after stroke. Method. Ten volunteers (62 ± 11 years, mean ± SD), 6 – 12 months after first-ever unilateral stroke, walking independently with or without aids were recruited. Using an A1-B-A2 design, 3 sets of baseline measures were taken at 2 weekly intervals; volunteers then attended twice weekly sessions of low intensity progressive strengthening exercises and were assessed after each series of 8 sessions to a maximum of 24 sessions; post training, measures were repeated after 4 – 6 weeks. Measures included isometric and concentric knee extensor muscle strength and 10 m walking velocity. Results. Strength of knee extensor muscles was improved after training (ANOVA, p < 0.05). On cessation of training, isometric strength increased by 58 ± 19% and concentric strength at 30°/s by 51 ± 14%; walking velocity quickened from 0.47 ± 0.06 m · s−1 to 0.57 ± 0.08 m · s−1 (t = −3.31, p < 0.01). These gains were maintained 4 – 6 weeks after completion of training. Conclusions. These findings support the use of low intensity strength training after stroke and confirm published evidence. It was feasible for one therapist to deliver the training programmes for 4 – 6 participants at a time; an important feature when resources are limited.

Can brain-injured patients participate in an aerobic exercise programme during early inpatient rehabilitation?

Objective: We investigated the capacity of brain-injured patients to participate in an aerobic exercise programme early after injury. Design: Retrospective analysis of exercise achievements in patients participating in a randomized controlled trial. Setting and subjects: Ninety patients participated in an exercise training programme on a cycle ergometer at four inpatient neurological rehabilitation units for younger patients. At intake, impairments and function were rated on: Motricity Index, Ashworth Scale, Berg Balance Scale, Barthel Index and Functional Independence Measure. Interventions: Patients cycled for up to 30 minutes three times weekly for 24–36 sessions over 12 weeks. Main outcome measures: Exercise performance was measured by: (a) number of sessions to achieve a cycling time of 30 minutes, (b) overall mean cycling time per session over 24 sessions and (c) mean time per session cycling at >60% of age predicted maximum heart rate (HR max) over 24 sessions. Results: Fifty-five patients completed 24 sessions. Thirty-five withdrew, largely for logistic reasons, before completing training; they were significantly less disabled than the 55 who remained. Forty-four of the 55 patients trained for an average of at least 20 minutes per session, 18 training at >60% HR max for this time. There were no differences in performance on the three exercise parameters between two groups of patients with baseline Barthel scores of ≤12 and ≥13. Conclusions: Brain-injured patients with a range of disabilities have the capacity to participate in an exercise programme during early inpatient rehabilitation, though some may take longer to achieve adequate intensity of aerobic exercise.

Comparison of muscle strength and in-vivo muscle morphology in young children with haemophilia and those of age-matched peers

Summary.  Recent advances in imaging have enhanced our understanding of the morphological adaptations of muscle in response to disease and altered use. Adaptation in muscle morphology has been linked to changes in muscle strength. To date, no studies have compared muscle morphology and strength in young children with haemophilia to that of typically developing children. This study explored differences in muscle strength and morphology between typically developing and age and size‐matched boys aged 6–12 years with haemophilia and a history of recurrent haemorrhage in the ankle joint. Maximum muscle strength of the knee flexors (KF), extensors (KE), ankle dorsi (ADF) and plantar flexors (APF) was measured in 19 typically developing boys (Group 1) and 19 boys with haemophilia (Group 2). Ultrasound images of vastus lateralis (VL) and lateral gastrocnemius (LG) were recorded to determine muscle cross‐sectional area (CSA), thickness, width, fascicle length and pennation angle. Muscle strength of the KE, ADF and APF were significantly (P < 0.05) lower in Group 2 when compared with Group 1. Muscle CSA and width of VL were significantly smaller and pennation angles significantly larger in Group 2 (P < 0.05). Muscle CSA and thickness of LG were significantly (P < 0.05) smaller in Group 2. Linear regression showed that LG muscle CSA and thickness were significant (P < 0.01) predictors of APF muscle strength. Following ankle joint bleeding in young boys with haemophilia, secondary adaptations in muscle strength and morphology were observed, suggesting that muscle function is more impaired than current clinical evaluations imply.

Exertional symptoms and exercise capacity in individuals with brain injury

Purpose. To examine factors affecting cycling exercise performance in individuals with acquired brain injury. Methods. Thirty individuals with acquired brain injury and 18 sedentary controls (SC) participated. Heart rate, bicycle power output and rating of perceived exertional (RPE) were recorded, throughout incremental cycle ergometer exercise. The SC group and 18 moderately impaired individuals from the ABI group performed a 25-W (B25) protocol. The remaining 12 individuals performed a 10-W protocol (B10). Results. The B10 group terminated exercise at the lowest RPE, percentage age predicted maximal heart rate (% APMHR) and bicycle power output, followed by the B25 and then the SC group (RPE: Kruskal – Wallis test P < 0.001, %APMHR and bicycle power output: one-way ANOVA P < 0.01). RPE was correlated with %APMHR and percentage of peak bicycle output (B10 group: R2 0.1 to 0.67; B25 group: 0.69 – 0.83; SC group: 0.76 – 0.91). There was no difference in RPE at the same relative work intensity between the B25 and the sedentary control group (P > 0.05). Forward regression analysis revealed fatigue levels were predictive of %APMHR at test termination (β = −0.411, P < 0.05) and quadriceps strength was predictive of peak bicycle power output (β = 0.612, P < 0.05). Conclusions. Individuals with brain injury terminated exercise at lower exercise intensities but rated exertion no differently from healthy individuals. General fatigue levels predicted %APMHR and quadriceps strength predicted peak bicycle power output.

Outcome measures monitoring physical function in children with haemophilia: a systematic review

Our objective was to provide a synthesis of measurement properties for performance‐based outcome measures used to evaluate physical function in children with haemophilia. A systematic review of articles published in English using Medline, PEDro, Cinahl and The Cochrane Library electronic databases was conducted. Studies were included if a performance‐based method, clinical evaluation or measurement tool was used to record an aspect of physical function in patients with haemophilia aged ≤ 18 years. Recording of self‐perceived or patient‐reported physical performance, abstracts, unpublished reports, case series reports and studies where the outcome measure was not documented or cross‐referenced was excluded. Description of outcome measures, patient characteristics, measurement properties for construct validity, internal consistency, repeatability, responsiveness and feasibility was extracted. Data synthesis of 41 studies evaluating 14 measures is reported. None of the outcome measures demonstrated the requirements for all the measurement properties. Data on validity and test–retest repeatability were most lacking together with studies of sufficient size. Measurement of walking and muscle strength demonstrated good repeatability and discriminative properties; however, correlation with other measures of musculoskeletal impairment requires investigation. The Haemophilia Joint Health Score demonstrated acceptable construct validity, internal consistency and repeatability, but the ability to discriminate changes in physical function is still to be determined. Rigorous evaluation of the measurement properties of performance‐based outcome measures used to monitor physical function of children with haemophilia in larger collaborative studies is required.

High-intensity cycling exercise after a stroke: a single case study

Aerobic exercise training has demonstrated positive effects after brain injury. However, therapists express concern regarding the use of effortful exercise in individuals presenting with spasticity or involuntary muscle activity. This study aimed to address this concern and to evaluate whether an intervention of maximal intensity cycling exercise impaired an individuals ability to actively extend his hemiparetic elbow. Using a single case design, it was shown that active elbow extension improved during the period of this investigation, and was not impaired immediately following maximal cycling exercise.

Biomechanics of lower limb haemophilic arthropathy.

Intermittent joint bleeding and potential arthropathy remain a concern for patients and those responsible for haemophilic care. Monitoring the status of haemophilic joints is a current challenge. Evaluation of bone and soft tissue with radiological imaging together with clinical joint scoring is often used to monitor haemophilic arthropathy and may not be sufficiently sensitive to early changes in joint morphology. Recently an interest in the biomechanical status of haemophilic joints has emerged. Biomechanics is defined as the interdiscipline that describes, analyses and assesses movement in relation to biological and physical principles. This review considers the biomechanical evaluation of haemophilic joint status of the lower limb with particular reference to the evaluation of muscle atrophy, muscle strength, range of motion and gait as well as the relationship to haemophilic arthropathy. In raising the need for increased clinical awareness, this review highlights the need to establish test-retest and inter-rater reliability and ensuring that comparative studies are undertaken with age-matched unaffected peer groups.

Hip muscle strength and function in very elderly women

Objective: To establish normative data for hip abductors and extensors and to investigate the relationship between these muscles, quadriceps femoris and functional ability. Subjects: Twenty healthy elderly women, mean age 84 ± 3.1 years took part; test-retest reliability was established in six healthy elderly women, mean age 75 ± 9.1 years. Main outcome measures: Isometric hip abductor, hip extensor and quadriceps femoris strength, leg extensor power (LEP), walking speed over 6 m, functional reach and stepping on to blocks of differing height. Results: Intraclass correlations of 0.98 and 0.99 and coefficient of variations (CV) between occasions of 4.7% and 7.2% were established for hip abductor and extensor measurements. The best correlations were between walking speed and strength of quadriceps femoris (p <0.001), between function reach and LEP (p <0.001). LEP was the most significant predictor of functional reach and step height climbed; quadriceps strength was the most significant predictor of walking speed. Conclusions: The data provide a baseline for future studies with less healthy women.