Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation.
Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation.
Primary objective: To determine if RTT improves upper limb function/reach and lower limb function/balance in adults after stroke.
Secondary objectives: 1) To determine the effect of RTT on secondary outcome measures including activities of daily living, global motor function, quality of life/health status and adverse events. 2) To determine the factors that could influence primary and secondary outcome measures, including the effect of ‘dose’ of task practice; type of task (whole therapy, mixed or single task); timing of the intervention and type of intervention.
We searched the Cochrane Stroke Group Trials Register (4 March 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 5: 1 October 2006 to 24 June 2016); MEDLINE (1 October 2006 to 8 March 2016); Embase (1 October 2006 to 8 March 2016); CINAHL (2006 to 23 June 2016); AMED (2006 to 21 June 2016) and SPORTSDiscus (2006 to 21 June 2016).
Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal.
Two review authors independently screened abstracts, extracted data and appraised trials. We determined the quality of evidence within each study and outcome group using the Cochrane ‘Risk of bias’ tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. We did not assess follow-up outcome data using GRADE. We contacted trial authors for additional information.
We included 33 trials with 36 intervention-control pairs and 1853 participants. The risk of bias present in many studies was unclear due to poor reporting; the evidence has therefore been rated ‘moderate’ or ‘low’ when using the GRADE system.
There is low-quality evidence that RTT improves arm function (standardised mean difference (SMD) 0.25, 95% confidence interval (CI) 0.01 to 0.49; 11 studies, number of participants analysed = 749), hand function (SMD 0.25, 95% CI 0.00 to 0.51; eight studies, number of participants analysed = 619), and lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48; five trials, number of participants analysed = 419).
There is moderate-quality evidence that RTT improves walking distance (mean difference (MD) 34.80, 95% CI 18.19 to 51.41; nine studies, number of participants analysed = 610) and functional ambulation (SMD 0.35, 95% CI 0.04 to 0.66; eight studies, number of participants analysed = 525). We found significant differences between groups for both upper-limb (SMD 0.92, 95% CI 0.58 to 1.26; three studies, number of participants analysed = 153) and lower-limb (SMD 0.34, 95% CI 0.16 to 0.52; eight studies, number of participants analysed = 471) outcomes up to six months post treatment but not after six months. Effects were not modified by intervention type, dosage of task practice or time since stroke for upper or lower limb. There was insufficient evidence to be certain about the risk of adverse events.
There is low- to moderate-quality evidence that RTT improves upper and lower limb function; improvements were sustained up to six months post treatment. Further research should focus on the type and amount of training, including ways of measuring the number of repetitions actually performed by participants. The definition of RTT will need revisiting prior to further updates of this review in order to ensure it remains clinically meaningful and distinguishable from other interventions.
Repetitive task training for improving functional ability after stroke
Review question: What are the effects of repeated practice of functional tasks on recovery after stroke when compared with usual care or placebo treatments?
Background: Stroke can cause problems with movement, often down one side of the body. While some recovery is common over time, about one third of people have continuing problems. Repeated practice of functional tasks (e.g. lifting a cup) is a treatment approach used to help with recovery of movement after stroke. This approach is based on the simple idea that in order to improve our ability to perform tasks we need to practice doing that particular task numerous times, like when we first learned to write. The types of practice that people do, and the time that they spend practicing, may affect how well this treatment works. To explore this further we also looked at different aspects of repetitive practice that may influence how well it works.
Study characteristics: We identified 33 studies with 1853 participants. Studies included a wide range of tasks to practice, including lifting a ball, walking, standing up from sitting and circuit training with a different task at each station. The evidence is current to June 2016.
Key results: In comparison with usual care (standard physiotherapy) or placebo groups, people who practiced functional tasks showed small improvements in arm function, hand function, walking distance and measures of walking ability. Improvements in arm and leg function were maintained up to six months later. There was not enough evidence to be certain about the risk of adverse events, for example falls. Further research is needed to determine the best type of task practice, and whether more sustained practice could show better results.
Quality of the evidence: We classified the quality of the evidence as low for arm function, hand function and lower limb functional measures, and as moderate for walking distance and functional ambulation. The quality of the evidence for each outcome was limited due poor reporting of study details (particularly in earlier studies), inconsistent results across studies and small numbers of study participants in some comparisons.
A patient with a left middle cerebral artery stroke was seen for physical therapy treatment for 8 sessions from 4/17/15 to 5/15/15 at the Department of Physical Therapy at California State University, Sacramento. Treatment was provided by a student physical therapist under the supervision of a licensed physical therapist.
The patient was evaluated at the initial encounter with the Five Times Sit to Stand to assess lower extremity muscular strength, the Six Minute Walk Test to assess cardiovascular endurance, the 10 Meter Walk Test to measure ambulatory status and gait speed, the Timed Up and Go test to measure fall risk, and the Falls Efficacy ScaleInternational to measure fall risk, and a plan of care was established. Main goals for the patient were to improve lower extremity strength, neuromuscular control, cardiovascular endurance, gait speed, and decrease risk for falls. Main interventions used were repetition, task-specific training, over-ground gait training, and neuromuscular control training.
The patient improved lower extremity strength, cardiovascular endurance, gait speed, and reduced her risk for falls. The patient was discharged to remain living at home with a home exercise program.
To measure the strength of the major muscle groups of the affected and intact lower limbs in people with stroke compared with age-matched controls.
Ambulatory stroke survivors (n=60; mean age, 69±11y), who had had a stroke between 1 and 6 years previously, and age-matched controls (n=35; mean age, 65±9y) (N=95).
The maximum isometric strength of 12 muscle groups (hip flexors and extensors, hip adductors and abductors, hip internal rotators and external rotators, knee flexors and extensors, ankle dorsiflexors and plantarflexors, ankle invertors and evertors) of both lower limbs was measured using handheld dynamometry. All strength measurements were taken in standardized positions by 1 rater.
The affected lower limb of the participants with stroke was significantly weaker than that of the control participants for all muscle groups (P<.01). Strength (adjusted for age, sex, and body weight) was 48% (range, 34%–62%) of that of the control participants. The most severely affected muscle groups were hip extensors (34% of controls), ankle dorsiflexors (35%), and hip adductors (38%), and the least severely affected muscle groups were ankle invertors (62%), ankle plantarflexors (57%), and hip flexors (55%). The intact lower limb of the participants with stroke was significantly weaker than that of the control participants for all muscle groups (P<.05) except for ankle invertors (P=.25). Strength (adjusted for age, sex, and body weight) was 66% (range, 44%–91%) of that of the control participants. The most severely affected muscle groups were hip extensors (44% of controls), ankle dorsiflexors (52%), and knee flexors (54%).
Ambulatory people with chronic stroke have a marked loss of strength in most of the major muscle groups of both lower limbs compared with age-matched controls.
Hemiplegia, apoplexia, or traffic accidents often lead to unilateral lower limb movement disorders. Traditional lower limb rehabilitation equipments usually execute walk training based on fixed gait trajectory; however, this type is unsuitable for unilateral lower limb disorders because they still have athletic ability and initiative walking intention on the healthy side.
This article describes a wearable lower limb rehabilitation exoskeleton with a walk-assisting platform for safety and anti-gravity support. The exoskeleton detects and tracks the motion of the healthy leg, which is then used as the control input of the dyskinetic leg with half a gate-cycle delay. The patient can undergo walk training on his own intention, including individual walking habit, stride length, and stride frequency, which likely contribute to the training initiative. The series elastic actuator is chosen for the exoskeleton because the torque output can be accurately detected and used to calculate the assisted torque on the dyskinetic leg. This parameter corresponds to the recovery level of a patient’s muscle force.
Finally, the walk-assisting experiments reveal that the rehabilitation exoskeleton in this article can provide the necessary assisting torques on the dyskinetic leg, which can be accurately monitored in real time to evaluate a patient’s rehabilitation status.
Human walking is the most basic mode of coordinated and voluntary movement with smooth transition, appropriate step length, and stable energy consumption.1Exercise therapy based on neurodevelopment facilitation theory is a fundamental rehabilitation method for lower limb movement disorders caused by hemiplegia, apoplexia, or accidental disability resulting from traffic accidents or natural disasters.2The application of rehabilitation exoskeletons can free physiotherapists from heavy manual labor and improve training efficiency in terms of the precise motion control and real-time recording of training parameters; this application contributes to the evaluation of rehabilitation. Rehabilitation exoskeletons can be broadly categorized into two types: lower limb wearable style and foot pedal style.
With the exoskeletons of the first type, patients usually undergo training on a treadmill; during training, both legs are tied to the exoskeleton and the upper body is supported by anti-gravity bundling belts. A suspension device is applied to balance the weight of the exoskeleton and part of the patient’s body weight. The exoskeletons of this style generally comprise a walk-assisting platform, an exoskeleton of the upper body, and two legs. Foot parts are usually not considered in these exoskeletons, such as WalkTrainer3 and Lokomat4 developed in Switzerland, SUBAR developed at Sogang University,5 ALEX developed at the University of Delaware,6 and lower limb walking assistant robot developed at Zhejiang University.7
For the second type, a pair of multi-variant pedal structures is connected to a patient’s feet for the rehabilitation training. The advantage of this approach is that uneven ground and changing terrains can be simulated to achieve training diversity. The Skywalker by MIT,8 the 6-degree-of-freedom (DOF) gait rehabilitation robot by Sogang University,9 and the Haptic Walker by Benjamin Franklin University10 are significant examples of the second type of exoskeletons.
Traditional lower limb rehabilitation equipments usually execute walk training by driving the legs on the basis of the fixed gait trajectory, which precludes a patient’s initiative. As such, they seem unsuitable for unilateral lower limb disorders because the equipment may interfere between the fixed gait trajectory and the initiative walking intention of the healthy leg.
This article proposes a wearable lower limb exoskeleton for the rehabilitation training of unilateral lower limb disorders. A wearable exoskeleton with a walk-assisting device has been designed to help during walk training. The exoskeleton detects and tracks the healthy leg’s motion in real time; the exoskeleton also provides the necessary assisting torque of the dyskinetic leg. The main design goals of this article are as follows: to improve the training initiative and to dynamically calculate the muscle torques on the dyskinetic leg, and these torques can be used as an evaluation index of rehabilitation training.
Background: Individuals post-stroke select slow comfortable walking speeds (CWS) and the major factors used to select their CWS is unknown.
Objective: To determine the extent to which slow CWS post-stroke is achieved through matching a relative force output or targeting a particular walking speed.
Methods: Ten neurologically nonimpaired individuals and fourteen chronic stroke survivors with hemiplegia were recruited. Participants were instructed to ?walk at the speed that feels most comfortable? on a treadmill against 12 progressively increasing horizontal resistive force levels applied at the pelvis using a robotic system that allowed participant to self-select their walking speed. We compared slope coefficients of the simple linear regressions between the observed normalized force vs. normalized speed relationship in each group to a slope of -1.0 (i.e. ideal slope for a constant relative force output) and 0.0 (i.e. ideal slope for a constant relative speed). We also compared slope coefficients between groups.
Results: The slope coefficients were significantly greater than -1.0 (p?<?0.001 for both) and significantly less than 0 (p?<?0.001 for both). However, compared with nonimpaired individuals, people post-stroke were less able to maintain their walking speed (p?=?0.003).
Conclusions: The results of this study provide evidence for a complex interaction between the regulation of relative force output and intention to move at a particular speed in the selection of the CWS for individuals post-stroke. This would suggest that therapeutic interventions should not only focus on task specific lower-limb strengthening exercises (e.g. walking against resistance), but should also focus on increasing the range of speeds at which people can safely walk.
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Objectives: Spasticity is defined as a pathological increase in muscle tonus, and increased muscle tonus of lower limbs is a major obstacle to the stroke rehabilitation. Foot baths are considered to provide beneficial thermal therapy for post-stroke patients with spasticity, but their anti-spastic effects have not been investigated comprehensively. The present study aimed to evaluate alterations in spasticity and motor function using foot baths in post-stroke patients with spastic hemiplegia.
Methods: We underwent two separate experiments each consisting of immersion in warm water up to the knee joint level, and measuring spasticity, physiological examination and motor function.
Experiment 1; Fourteen post-stroke patients with lower limb spasticity were enrolled in this study (nine males and five females; mean age 50.4±12.9 years; range, 28-65 years). The subjects’ legs from below the knee joint were immersed in water at 41°C for 15 min. Measurements of F-waves and a physiological examination were carried out immediately (within 5 min) after the foot-bath session, and again 30 min later, while the subject remained wrapped in blankets on the lift-bath stretcher.
Experiment 2; Six post-stroke patients with lower limb spasticity were enrolled in this study (five males and one female; mean age 55.2±14.6 years; range, 39-68 years). The subjects’ legs from below the knee joint were immersed in the artificial high concentration carbon-dioxide (CO2) water or tap water foot bath at 38°C for 30 min. Measurements of muscle stiffness, motor function (active range of motion: A-ROM) and a physiological examination were carried out immediately (within 5 min) after the foot-bath session, and again 10 min later, while the subject remained wrapped in blankets.
Results: None of the subjects experienced discomfort before, during or after the foot-bath treatment. The physiological examination was completed safely in all subjects.
Experiment 1; The mean values of F-wave parameters were significantly reduced after foot-bath treatment (P<0.01). The anti-spastic effects of foot-bath treatment were indicated by decreased F-wave parameters, in parallel with decreases in modified Ashworth scale (MAS) score. The body temperature was significantly increased both immediately after, and 30 min following foot-bath treatment.
Experiment 2; The changes both in the body and surface skin temperature were higher in the artificial high concentration CO2 water foot bath compared with the tap water foot bath. The changes in the MAS score, muscle stiffness and A-ROM were also higher in the high concentration CO2 water foot bath than in the tap water foot bath.
Conclusion: These findings demonstrate that the use of foot baths is an effective non-pharmacological anti-spastic treatment that might facilitate stroke rehabilitation. In addition, the high concentration CO2 water foot baths appeared to play an important role in decreased spasticity.
More and more stroke survivors are suffering from physical motor impairments. Current therapeutic interventions have various limits to the efficient recovery of normal motor function of the lower limbs. Therefore, we propose a novel gait rehabilitation system for hemiplegic patients after stroke. It integrates functional electrical stimulation (FES) with a pelvis-supporting robotic system. A corresponding relationship between the gait phase and the active lateral movement of the pelvis is first constructed from experiments on simulated hemiplegic patients. By estimating the gait phase from the lateral motion of the pelvis based on this relationship, the timing of FES sent to the muscles of the lower limbs can be automatically determined during a gait cycle. After experiments on simulated hemiplegic stroke survivors with the FES control algorithm, the proposed algorithm and the gait rehabilitation system are verified to be feasible and promising.