Robert C. Wagenaar

Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomised trial

BACKGROUND We investigated the effects of different intensities of arm and leg rehabilitation training on the functional recovery of activities of daily living (ADL), walking ability, and dexterity of the paretic arm, in a single-blind randomised controlled trial. METHODS Within 14 days after stroke onset, 101 severely disabled patients with a primary middle-cerebral-artery stroke were randomly assigned to: a rehabilitation programme with emphasis on arm training; a rehabilitation programme with emphasis on leg training; or a control programme in which the arm and leg were immobilised with an inflatable pressure splint. Each treatment regimen was applied for 30 min, 5 days a week during the first 20 weeks after stroke. In addition, all patients underwent a basic rehabilitation programme. The main outcome measures were ability in ADL (Barthel index), walking ability (functional ambulation categories), and dexterity of the paretic arm (Action Research arm test) at 6, 12, 20, and 26 weeks. Analyses were by intention to treat. FINDINGS At week 20, the leg-training group (n=31) had higher scores than the control group (n=37) for ADL ability (median 19 [IQR 16-20] vs 16 [10-19], p<0.05), walking ability (4 [3-5] vs 3 [1-4], p<0.05), and dexterity (2 [0-56] vs 0 [0-2], p<0.01). The arm-training group (n=33) differed significantly from the control group only in dexterity (9 [0-39] vs 0 [0-2], p<0.01). There were no significant differences in these endpoints at 20 weeks between the arm-training and leg-training groups. INTERPRETATION Greater intensity of leg rehabilitation improves functional recovery and health-related functional status, whereas greater intensity of arm rehabilitation results in small improvements in dexterity, providing further evidence that exercise therapy primarily induces treatment effects on the abilities at which training is specifically aimed.

Effects of Augmented Exercise Therapy Time After Stroke A Meta-Analysis

Background and Purpose— To present a systematic review of studies that addresses the effects of intensity of augmented exercise therapy time (AETT) on activities of daily living (ADL), walking, and dexterity in patients with stroke. Summary of Review— A database of articles published from 1966 to November 2003 was compiled from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE, and PiCarta using combinations of the following key words: stroke, cerebrovascular disorders, physical therapy, physiotherapy, occupational therapy, exercise therapy, rehabilitation, intensity, dose–response relationship, effectiveness, and randomized controlled trial. References presented in relevant publications were examined as well as abstracts in proceedings. Studies that satisfied the following selection criteria were included: (1) patients had a diagnosis of stroke; (2) effects of intensity of exercise training were investigated; and (3) design of the study was a randomized controlled trial (RCT). For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) expressed in standard deviation units (SDU) were calculated for ADL, walking speed, and dexterity using fixed and random effect models. Correlation coefficients were calculated between observed individual effect sizes on ADL of each study, additional time spent on exercise training, and methodological quality. Cumulative meta-analyses (random effects model) adjusted for the difference in treatment intensity in each study was used for the trials evaluating the effects of AETT provided. Twenty of the 31 candidate studies, involving 2686 stroke patients, were included in the synthesis. The methodological quality ranged from 2 to 10 out of the maximum score of 14 points. The meta-analysis resulted in a small but statistically significant SES with regard to ADL measured at the end of the intervention phase. Further analysis showed a significant homogeneous SES for 17 studies that investigated effects of increased exercise intensity within the first 6 months after stroke. No significant SES was observed for the 3 studies conducted in the chronic phase. Cumulative meta-analysis strongly suggests that at least a 16-hour difference in treatment time between experimental and control groups provided in the first 6 months after stroke is needed to obtain significant differences in ADL. A significant SES supporting a higher intensity was also observed for instrumental ADL and walking speed, whereas no significant SES was found for dexterity. Conclusion— The results of the present research synthesis support the hypothesis that augmented exercise therapy has a small but favorable effect on ADL, particularly if therapy input is augmented at least 16 hours within the first 6 months after stroke. This meta-analysis also suggests that clinically relevant treatment effects may be achieved on instrumental ADL and gait speed.

Forced Use of the Upper Extremity in Chronic Stroke Patients Results From a Single-Blind Randomized Clinical Trial

BACKGROUND AND PURPOSE Of all stroke survivors, 30% to 66% are unable to use their affected arm in performing activities of daily living. Although forced use therapy appears to improve arm function in chronic stroke patients, there is no conclusive evidence. This study evaluates the effectiveness of forced use therapy. METHODS In an observer-blinded randomized clinical trial, 66 chronic stroke patients were allocated to either forced use therapy (immobilization of the unaffected arm combined with intensive training) or a reference therapy of equally intensive bimanual training, based on Neuro-Developmental Treatment, for a period of 2 weeks. Outcomes were evaluated on the basis of the Rehabilitation Activities Profile (activities), the Action Research Arm (ARA) test (dexterity), the upper extremity section of the Fugl-Meyer Assessment scale, the Motor Activity Log (MAL), and a Problem Score. The minimal clinically important difference (MCID) was determined at the onset of the study. RESULTS One week after the last treatment session, a significant difference in effectiveness in favor of the forced use group compared with the bimanual group (corrected for baseline differences) was found for the ARA score (3.0 points; 95% CI, 1.3 to 4.8; MCID, 5.7 points) and the MAL amount of use score (0.52 points; 95% CI, 0.11 to 0.93; MCID, 0.50). The other parameters revealed no significant differential effects. One-year follow-up effects were observed only for the ARA. The differences in treatment effect for the ARA and the MAL amount of use scores were clinically relevant for patients with sensory disorders and hemineglect, respectively. CONCLUSIONS The present study showed a small but lasting effect of forced use therapy on the dexterity of the affected arm (ARA) and a temporary clinically relevant effect on the amount of use of the affected arm during activities of daily living (MAL amount of use). The effect of forced use therapy was clinically relevant in the subgroups of patients with sensory disorders and hemineglect, respectively.

Effects of Intensity of Rehabilitation After Stroke A Research Synthesis

BACKGROUND AND PURPOSE A research synthesis was performed to (1) critically review controlled studies evaluating effects of different intensities of stroke rehabilitation in terms of disabilities and impairments and (2) quantify patterns by calculating summary effect sizes. The influences of organizational setting of rehabilitation management, blind recording, and amount of rehabilitation on the summary effect sizes were calculated. METHODS A Medline literature search was performed for a critical review of the literature. The internal and external validity of the studies was evaluated. In addition, a meta-analysis was performed by applying the fixed (Hedgess g) effects model. RESULTS The effects of different intensities of rehabilitation were studied in nine controlled studies involving 1051 patients. Analysis of the methodological quality revealed scores varying from 14% to 47% of the maximum feasible score. Meta-analysis demonstrated a statistically significant summary effect size for activities of daily living (0.28 +/- 0.12). Lower summary effect sizes (0.19 +/- 0.17) were found for studies in which experimental and control groups were treated in the same setting compared with studies in which the two groups of patients were treated in different settings (0.40 +/- 0.19). Variables defined on a neuromuscular level (0.37 +/- 0.24) showed larger summary effect sizes than variables defined on a functional level (0.10 +/- 0.21). Weighting individual effect sizes for the difference in amount of rehabilitation between experimental and control groups resulted in larger summary effect sizes for activities of daily living and functional outcome parameters for studies that were not confounded by organizational setting. CONCLUSIONS A small but statistically significant intensity-effect relationship in the rehabilitation of stroke patients was found. Insufficient contrast in the amount of rehabilitation between experimental and control conditions, organizational setting of rehabilitation management, lack of blinding procedures, and heterogeneity of patient characteristics were major confounding factors.

Hemiplegic gait: A kinematic analysis using walking speed as a basis

The kinematics of treadmill ambulation of stroke patients (N = 9) and healthy subjects (N = 4) was studied at a wide range of different velocities (i.e. 0.25-1.5 m s-1), with a focus on the transverse rotations of the trunk. Video recordings revealed, for both stroke patients and healthy subjects, similar relations between walking speed and stride length as well as stride frequency. The phase difference between pelvic and thoracic rotations (i.e. trunk rotation) and the total range of trunk rotation were almost linearly related to the walking speed. Healthy subjects showed a marked increase in pelvic rotation from 1 to 1.5 m s-1. Using dimensional analysis in a comparison between stroke patients and healthy subjects, invariances in the coordination of gait were found for stride length, stride frequency, pelvic rotation, and trunk rotation. Constant relations were obtained between, on the one hand, dimensionless velocity and, on the other, dimensionless stride length as well as stride frequency. Transitions were found between the velocities 0.75 and 1 m s-1 for dimensionless pelvic rotation and trunk rotation, indicating that, from this velocity range onwards, pelvic swing lengthens the stride: rotations of pelvis, thorax and trunk become tightly coordinated. On the basis of the dimensionless stride length, stride frequency, pelvic rotation and trunk rotation, deficits in the gait of stroke patients could be quantified. It is concluded that walking speed is an important control parameter, which should be used as a basic variable in the evaluation of the gait of stroke patients.

Exercise therapy for arm function in stroke patients: a systematic review of randomized controlled trials

Objective: Assessment of the available evidence for the effectiveness of exercise therapy to improve arm function in patients who have suffered from a stroke. Methods: A systematic search of bibliographical databases and reference checking were performed to identify publications on randomized controlled trials (RCTs) which evaluated the effect of exercise therapy on arm function in stroke patients. The methodological quality was assessed systematically by two raters, based on a standardized list of methodological criteria. Study characteristics, such as the chronicity and severity of impairment of the patient population, the amount and duration of interventions, and specific methodological criteria, were related to reported effects. Results: Thirteen RCTs were identified, six of which reported positive results on an arm function test. In five of these six studies there was a contrast in amount or duration of exercise therapy between groups. Methodological scores ranged from 5 to 15 (maximum possible score: 19 points). Conclusion: Insufficient evidence made it impossible to draw definitive conclusions about the effectiveness of exercise therapy on arm function in stroke patients. The difference in results between studies with and without contrast in the amount or duration of exercise therapy between groups suggests that more exercise therapy may be beneficial.

Gait Characteristics of Elderly People With a History of Falls: A Dynamic Approach

Background and Purpose. This study investigated changes in the kinematics of elderly people who experienced at least one fall 6 months prior to data collection. The authors hypothesized that, in order to decrease variability of walking, people with a history of falls would show different kinematic adaptations of their walking patterns compared with elderly people with no history of falls. Subjects and Methods. Twenty-one elderly people who had fallen within the previous 6 months (“fallers”; mean age=72.1 years, SD=4.9) and 27 elderly people with no history of falls (“nonfallers”; mean age=73.8 years, SD=6.4) walked at their preferred stride frequency (STF) as treadmill speed was gradually increased (from 0.18 m/s to 1.52 m/s) and then decreased in steps of 0.2 m/s. Gait parameter measurements were recorded, and statistical analysis was applied using walking speed and STF as independent variables. Results. Fifty-seven percent of the fallers were unable to walk at the fastest speed, whereas all nonfallers walked comfortably at all walking speeds. Although the fallers showed significantly greater STF, smaller stride lengths, smaller center-of-mass lateral sway, and smaller ankle plantar flexion and hip extension during push-off, they showed increased variability of kinematic measures in their coordination of walking compared with the nonfallers. Discussion and Conclusion. Although the fallers’ adaptations were expected to reduce variability in the coordination of walking, they showed less stable gait patterns (ie, greater variability) compared with the nonfallers. Increased variability of walking patterns may be an important gait risk factor in elderly people with a history of falls.

Therapy Impact on Functional Recovery in Stroke Rehabilitation: A critical review of the literature

Summary Optimal functional recovery is the ultimate goal in stroke rehabilitation. Evidence-based practice requires scientific evaluation of existing treatment programmes as well as research into new therapeutic strategies and comprehensive services. A number of studies have reported that stroke patients admitted to specialised stroke units are more likely to benefit from medical and paramedical treatment than patients on general wards. To date multiple clinical studies demonstrate no clear difference in effectiveness between therapeutic approaches in stroke rehabilitation. However, deficiencies in designs of randomised trials compromise methodological quality. Detecting minor treatment effects in stroke rehabilitation requires adequate statistical power, homogeneity in stroke population and the application of responsive tests. Accurate and reliable predictors of functional recovery are needed to set realistic and attainable treatment goals. However, spontaneous neurological recovery is most likely to be responsible for most functional recovery. Additional rehabilitation-induced effects may be generated due to biological variability. Comprehensive functional therapy incorporating elements of intensive and task-specific strategies is most likely to result in therapeutic effects.

How do load carriage and walking speed influence trunk coordination and stride parameters

To determine the effects of load carriage and walking speed on stride parameters and the coordination of trunk movements, 12 subjects walked on a treadmill at a range of walking speeds (0.6-1.6 m s(-1)) with and without a backpack containing 40% of their body mass. It was hypothesized that compared to unloaded walking, load carriage decreases transverse pelvic and thoracic rotation, the mean relative phase between pelvic and thoracic rotations, and increases hip excursion. In addition, it was hypothesized that these changes would coincide with a decreased stride length and increased stride frequency. The findings supported the hypotheses. Dimensionless analyses indicated that there was a significantly larger contribution of hip excursion and smaller contribution of transverse plane pelvic rotation to increases in stride length during load carriage. In addition, there was a significant effect of load carriage on the amplitudes of transverse pelvic and thoracic rotation and the relative phase of pelvic and thoracic rotation. It was concluded that the shorter stride length and higher stride frequency observed when carrying a backpack is the result of decreased pelvic rotation. During unloaded walking, increases in pelvic rotation contribute to increases in stride length with increasing walking speed. The decreased pelvic rotation during load carriage requires an increased hip excursion to compensate. However, the increase in hip excursion is insufficient to fully compensate for the observed decrease in pelvis rotation, requiring an increase in stride frequency during load carriage to maintain a constant walking speed.

Resonant frequencies of arms and legs identify different walking patterns

The present study is aimed at investigating changes in the coordination of arm and leg movements in young healthy subjects. It was hypothesized that with changes in walking velocity there is a change in frequency and phase coupling between the arms and the legs. In addition, it was hypothesized that the preferred frequencies of the different coordination patterns can be predicted on the basis of the resonant frequencies of arms and legs with a simple pendulum model. The kinematics of arms and legs during treadmill walking in seven healthy subjects were recorded with accelerometers in the sagittal plane at a wide range of different velocities (i.e., 0.3-1. 3m/s). Power spectral analyses revealed a statistically significant change in the frequency relation between arms and legs, i.e., within the velocity range 0.3-0.7m/s arm movement frequencies were dominantly synchronized with the step frequency, whereas from 0.8m/s onwards arm frequencies were locked onto stride frequency. Significant effects of walking speed on mean relative phase between leg and arm movements were found. All limb pairs showed a significantly more stable coordination pattern from 0.8 to 1.0m/s onwards. Results from the pendulum modelling demonstrated that for most subjects at low-velocity preferred movement frequencies of the arms are predicted by the resonant frequencies of individual arms (about 0.98Hz), whereas at higher velocities these are predicted on the basis of the resonant frequencies of the individual legs (about 0.85Hz). The results support the above-mentioned hypotheses, and suggest that different patterns of coordination, as shown by changes in frequency coupling and phase relations, can exist within the human walking mode.