Does progressive resistance training improve strength and activity after stroke? Does any increase in strength carry over to activity?
Does progressive resistance training improve strength and activity after stroke? Does any increase in strength carry over to activity?
Systematic review of randomised trials with meta-analysis.
Adults who have had a stroke.
Progressive resistance training compared with no intervention or placebo.
The primary outcome was change in strength. This measurement had to be of maximum voluntary force production and performed in muscles congruent with the muscles trained in the intervention. The secondary outcome was change in activity. This measurement had to be a direct measure of performance that produced continuous or ordinal data, or with scales that produced ordinal data.
Eleven studies involving 370 participants were included in this systematic review. The overall effect of progressive resistance training on strength was examined by pooling change scores from six studies with a mean PEDro score of 5.8, representing medium quality. The effect size of progressive resistance training on strength was 0.98 (95% CI 0.67 to 1.29, I2 = 0%). The overall effect of progressive resistance training on activity was examined by pooling change scores from the same six studies. The effect size of progressive resistance training on activity was 0.42 (95% CI –0.08 to 0.91, I2 = 54%).
After stroke, progressive resistance training has a large effect on strength compared with no intervention or placebo. There is uncertainty about whether these large increases in strength carry over to improvements in activity.
Virtual-reality based rehabilitation (VR) shows potential as an engaging and effective way to improve upper-limb function and cognitive abilities following a stroke. However, an updated synthesis of the literature is needed to capture growth in recent research and address gaps in our understanding of factors that may optimize training parameters and treatment effects.
Published randomized controlled trials comparing VR to conventional therapy were retrieved from seven electronic databases. Treatment effects (Hedge’s g) were estimated using a random effects model, with motor and functional outcomes between different protocols compared at the Body Structure/Function, Activity, and Participation levels of the International Classification of Functioning.
Thirty-three studies were identified, including 971 participants (492 VR participants). VR produced small to medium overall effects (g = 0.46; 95% CI: 0.33–0.59, p < 0.01), above and beyond conventional therapies. Small to medium effects were observed on Body Structure/Function (g = 0.41; 95% CI: 0.28–0.55; p < 0.01) and Activityoutcomes (g = 0.47; 95% CI: 0.34–0.60, p < 0.01), while Participationoutcomes failed to reach significance (g = 0.38; 95% CI: -0.29-1.04, p = 0.27). Superior benefits for Body Structure/Function (g = 0.56) and Activity outcomes (g = 0.62) were observed when examining outcomes only from purpose-designed VR systems. Preliminary results (k = 4) suggested small to medium effects for cognitive outcomes (g = 0.41; 95% CI: 0.28–0.55; p < 0.01). Moderator analysis found no advantage for higher doses of VR, massed practice training schedules, or greater time since injury.
VR can effect significant gains on Body Structure/Function and Activity level outcomes, including improvements in cognitive function, for individuals who have sustained a stroke. The evidence supports the use of VR as an adjunct for stroke rehabilitation, with effectiveness evident for a variety of platforms, training parameters, and stages of recovery.
Stroke is one of the leading global causes of disability [1, 2], with over 17 million individuals worldwide sustaining a stroke each year . Although stroke mortality is decreasing with improvements in medical technology , the neurological trauma resulting from stroke can be devastating, and the majority of stroke survivors have substantial motor [4, 5], cognitive [6, 7, 8, 9] and functional rehabilitation needs [3, 10, 11], and much reduced quality of life [3, 12, 13]. Targeted rehabilitation can help address some of these post-stroke deficits, however, historically, many individuals, in particular patients with cognitive impairment, have difficulty engaging in standard therapies [14, 15, 16] at a level that will produce meaningful and lasting improvements [16, 17, 18, 19]. Enriched and interactive rehabilitation programs are clearly needed to minimize functional disability [13, 20], increase participation in age-appropriate roles and activities , lead to greater motivation and treatment compliance [17, 22], and reduce the long-term expense of care in stroke survivors [20, 23, 24].[…]
Continue —> What do randomized controlled trials say about virtual rehabilitation in stroke? A systematic literature review and meta-analysis of upper-limb and cognitive outcomes | Journal of NeuroEngineering and Rehabilitation | Full Text
To investigate the therapeutic interventions reported in the research literature and synthesize their effectiveness in improving upper limb (UL) function in the first 4 weeks poststroke.
Electronic databases and trial registries were searched from inception until June 2016, in addition to searching systematic reviews by hand.
Randomized controlled trials (RCTs), controlled trials, and interventional studies with pre/posttest design were included for adults within 4 weeks of any type of stroke with UL impairment. Participants all received an intervention of any physiotherapeutic or occupational therapeutic technique designed to address impairment or activity of the affected UL, which could be compared with usual care, sham, or another technique.
Two reviewers independently assessed eligibility of full texts, and methodological quality of included studies was assessed using the Cochrane Risk of Bias Tool.
A total of 104 trials (83 RCTs, 21 nonrandomized studies) were included (N=5225 participants). Meta-analyses of RCTs only (20 comparisons) and narrative syntheses were completed. Key findings included significant positive effects for modified constraint-induced movement therapy (mCIMT) (standardized mean difference [SMD]=1.09; 95% confidence interval [CI], .21–1.97) and task-specific training (SMD=.37; 95% CI, .05–.68). Evidence was found to support supplementary use of biofeedback and electrical stimulation. Use of Bobath therapy was not supported.
Use of mCIMT and task-specific training was supported, as was supplementary use of biofeedback and electrical simulation, within the acute phase poststroke. Further high-quality studies into the initial 4 weeks poststroke are needed to determine therapies for targeted functional UL outcomes.
via Rehabilitation Interventions for Upper Limb Function in the First Four Weeks Following Stroke: A Systematic Review and Meta-Analysis of the Evidence – Archives of Physical Medicine and Rehabilitation
To systematically review evidence on the effects of timing and intensity of neurorehabilitation on the functional recovery of patients with moderate to severe traumatic brain injury (TBI) and aggregate the available evidence using meta-analytic methods.
Pubmed, Embase, PsycINFO and Cochrane Database.
Electronic databases were searched for prospective controlled clinical trials assessing the effect of timing or intensity of multidisciplinary neurorehabilitation programs on functional outcome of patients with moderate or severe TBI. A total of 5,961 unique records were screened for relevance, of which 58 full-text articles were assessed for eligibility by two independent authors. Eleven articles were included for systematic review and meta-analysis.
Two independent authors performed data extraction and risk of bias analysis using the Cochrane Collaboration Tool. Discrepancies between authors were resolved by consensus.
Systematic review of a total of six randomized controlled trials, one quasi-randomized trails and four controlled trials revealed consistent evidence for a beneficial effect of early onset neurorehabilitation in the trauma center and intensive neurorehabilitation in the rehabilitation facility on functional outcome, as compared to usual care. Meta-analytic quantification revealed a large-sized positive effect for early onset rehabilitation programs (d = 1.02, p < .001, 95%-confidence interval [CI]: 0.56-1.47) and a medium-sized positive effect for intensive neurorehabilitation programs (d = 0.67, p < .001. 95%-CI: 0.38-0.97) as compared to usual care. These effects were replicated based on solely studies with a low overall risk of bias.
The available evidence indicates that early onset neurorehabilitation in the trauma center and more intensive neurorehabilitation in the rehabilitation facility promote functional recovery of patients with moderate to severe TBI as compared to usual care. These findings support the integration of early onset and more intensive neurorehabilitation in the chain of care for patients with TBI.
via The Effects of Timing and Intensity of Neurorehabilitation on Functional Outcome after Traumatic Brain Injury: a Systematic Review & Meta-Analysis – Archives of Physical Medicine and Rehabilitation
Objective: To evaluate the influence of transcutaneous electrical nerve stimulation in patients with stroke through a systematic review and meta-analysis.
Methods: PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases were searched systematically. Randomized controlled trials assessing the effect of transcutaneous electrical nerve stimulation vs placebo transcutaneous electrical nerve stimulation on stroke were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcome was modified Ashworth scale (MAS). Meta-analysis was performed using the random-effect model.
Results: Seven randomized controlled trials were included in the meta-analysis. Compared with placebo transcutaneous electrical nerve stimulation, transcutaneous electrical nerve stimulation supplementation significantly reduced MAS (standard mean difference (SMD) = –0.71; 95% confidence interval (95% CI) = –1.11 to –0.30; p =0.0006), improved static balance with open eyes (SMD = –1.26; 95% CI = –1.83
to –0.69; p<0.0001) and closed eyes (SMD = –1.74; 95% CI = –2.36 to –1.12; p < 0.00001), and increased walking speed (SMD = 0.44; 95% CI = 0.05 to 0.84; p = 0.03), but did not improve results on the Timed Up and Go Test (SMD = –0.60; 95% CI=–1.22 to 0.03; p = 0.06).
Conclusion: Transcutaneous electrical nerve stimulation is associated with significantly reduced spasticity, increased static balance and walking speed, but has no influence on dynamic balance.
Background: Survivors of stroke have long-term physical and psychological consequences that impact their quality of life. Few interventions are available in the community to address these problems. Yoga, a type of mindfulness-based intervention, is shown to be effective in people with other chronic illnesses and may have the potential to address many of the problems reported by survivors of stroke.
Objectives: To date only narrative reviews have been published. We sought to perform, the first systematic review with meta-analyses of randomized controlled trials (RCTs) that investigated yoga for its potential benefit for chronic survivors of stroke.
Methods: Ovid Medline, CINHAL plus, AMED, PubMed, PsychINFO, PeDro, Cochrane database, Sport Discuss, and Google Scholar were searched for papers published between January 1950 and August 2016. Reference lists of included papers, review articles and OpenGrey for Grey literature were also searched. We used a modified Cochrane tool to evaluate risk of bias. The methodological quality of RCTs was assessed using the GRADE approach, results were collated, and random effects meta-analyses performed where appropriate.
Results: The search yielded five eligible papers from four RCTs with small sample sizes (n = 17–47). Quality of RCTs was rated as low to moderate. Yoga is beneficial in reducing state anxiety symptoms and depression in the intervention group compared to the control group (mean differences for state anxiety 6.05, 95% CI:−0.02 to 12.12; p = 0.05 and standardized mean differences for depression: 0.50, 95% CI:−0.01 to 1.02; p = 0.05). Consistent but nonsignificant improvements were demonstrated for balance, trait anxiety, and overall quality of life.
Conclusions: Yoga may be effective for ameliorating some of the long-term consequences of stroke. Large well-designed RCTs are needed to confirm these findings.
This study aimed to evaluate effects of motor imagery (MI) on walking function and balance in patients after stroke.
Related randomized controlled trials (RCTs) were searched in 12 electronic databases (Cochrane Central Register of Controlled Trials, PubMed, Science Direct, Web of Science, Allied and Complementary Medicine, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, WanFang, and VIP) from inception to November 30, 2016, and Review Manager 5.3 was used for meta-analysis. References listed in included papers and other related systematic reviews on MI were also screened for further consideration.
A total of 17 studies were included. When compared with “routine methods of treatment or training,” meta-analyses showed that MI was more effective in improving walking abilities (standardized mean difference [SMD] = 0.69, random effect model, 95% confidence interval [CI] = 0.38 to 1.00, P < 0.0001) and motor function in stroke patients (SMD = 0.84, random effect model, 95% CI = 0.45 to 1.22, P < 0.0001), but no statistical difference was noted in balance (SMD = 0.78, random effect model, 95% CI = −0.07 to 1.62, P = 0.07). Statistically significant improvement in walking abilities was noted between short-term (0 to < six weeks) (SMD = 0.83, fixed effect model, 95% CI = 0.24 to 1.42, P = 0.006) and long-term (≥six weeks) durations (SMD = 0.45, fixed effect model, 95% CI = 0.25 to 0.64, P < 0.00001). Subgroup analyses results suggested that MI had a positive effect on balance with short-term duration (0 to < six weeks) (SMD = 4.67, fixed effect model, 95% CI = 2.89 to 6.46, P < 0.00001), but failed to improve balance (SMD = 0.82, random effect model, 95% CI = −0.27 to 1.90, P = 0.14) with long-term (≥six weeks) duration.
MI appears to be a beneficial intervention for stroke rehabilitation. Nonetheless, existing evidence regarding effectiveness of MI in stroke patients remains inconclusive because of significantly statistical heterogeneity and methodological flaws identified in the included studies. More large-scale and rigorously designed RCTs in future research with sufficient follow-up periods are needed to provide more reliable evidence on the effect of MI on stroke patients.
Evidence for the effectiveness of serious games (SGs) and their various features is inconsistent in the motor rehabilitation field, which makes evidence based development of SGs a rare practice.
To investigate the effectiveness of SGs in motor rehabilitation for upper limb and movement/balance and to test the potential moderating role of SGs features like feedback, activities, characters and background.
We ran a meta-analysis including 61 studies reporting randomized controlled trials (RCTs), controlled trials (CTs) or case series designs in which at least one intervention for motor rehabilitation included the use of SGs as standalone or in combination.
There was an overall moderate effect of SGs on motor indices, d = 0.59, [95% CI, 0.48, 0.71], p < 0.001. Regarding the game features, only two out of 17 moderators were statistically different in terms of effect sizes: type of activity (combination of group with individual activities had the highest effects), and realism of the scenario (fantasy scenarios had the highest effects).
While we showed that SGs are more effective in improving motor upper limb and movement/balance functions compared to conventional rehabilitation, there were no consistent differences between various game features in their contribution to effects. Further research should systematically investigate SGs features that might have added value in improving effectiveness.
To evaluate the effects and safety of electro-acupuncture (EA) for stroke patients with spasticity.
Five English (PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and AMED) and four Chinese databases (CBM, CNKI, CQVIP and Wanfang) were searched from their inception to September 2016.
Randomized controlled trials were included if they measured spasticity with Modified Ashworth Scale in stroke patients and investigated the add-on effects of electro-acupuncture to routine pharmacotherapy and rehabilitation therapies.
Information on patients, study design, treatment details and outcomes assessing spasticity severity, motor function and activity of daily living were extracted.
In total, 22 trials met the search criteria and were included involving 1,425 participants. The estimated add-on effects of EA to reduce spasticity in upper limb measured by MAS (SMD: -0.57[-0.84, -0.29]) and improve overall motor function measured by FMA (MD: 10.60[8.67, 12.53]) were significant. It was also found that for spasticity in lower limb, lower-limb motor function and activity of daily living, significant add-on effects of EA were also shown (SMD: -0.88[-1.42, -0.35], MD:4.42[0.06, 8.78] and MD: 6.85[3.64, 10.05] respectively), though with high heterogeneity. For upper-limb motor function, no significant add-on effects of EA was received.
Electro-acupuncture combined with conventional routine care has the potential of reducing spasticity in upper and lower limb and improving overall and lower extremity motor function and activity of daily living for spasticity patients within 180 days post stroke. Further studies of high methodological and reporting quality are needed to confirm the effects and safety of electro-acupuncture, and to explore the adequate and optimal protocol of EA for post-stroke spasticity incorporating a group of comprehensive outcome measures in different populations.
Stroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.
Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.
Twenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [−0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD −0.10; CI [−0.59, 0.38], n = 35).
Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.
FES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.
Stroke is defined as a clinical syndrome characterised by rapidly developing focal or global disturbance in cerebral function lasting more than 24 h or leading to death due to a presumed vascular cause . Globally, approximately 16 million people have a stroke each year  and in the UK, first-ever stroke affects about 230 people per 100,000 population each year . Stroke represents a cost to the UK economy of approximately £9 billion annually, of which £1.33 billion results from productivity losses .
Stroke often leads to significant impairment of upper limb function and is associated with decreased quality of life in all domains except for mobility . Few patients attain complete functional recovery ; this deficit impairs performance of activities of daily living (ADL), including self-care and social activities [7, 8]. ADL reflect the level of functional impairment in daily life and are therefore the most clinically relevant outcome measures in assessing recovery after stroke .
Functional electrical stimulation (FES) was well established as an intervention for motor rehabilitation. FES is the electrical stimulation of motor neurons such that muscle groups are stimulated to contract and create/augment a moment about a joint . Transcutaneous electrodes offer the most immediate and clinically viable treatment option as they are non-invasive and may permit home-based treatment.
There are various terms used in the literature to describe different forms of electrical stimulation, often inconsistently. Some authors define FES as electrical stimulation applied to a subject which causes muscle contraction. This passive modality is also referred to as neuromuscular electrical stimulation . Others define FES as electrical stimulation applied during a voluntary movement . This definition acknowledges the volitional component of physical rehabilitation and was used in this systematic review. The distinction is important because neuroimaging studies have identified different cortical mechanisms according to stimulation type [11, 12, 13]. Indeed, perfusion to the ipsilesional sensory-motor cortex and cortical excitability were increased with FES when compared to passive modalities of electrical stimulation [12, 13, 14]. These findings could indicate greater potential for volitional FES to induce neuroplasticity. This is believed to play an important role in neurorehabilitation  and is a key objective of post-stroke functional recovery .
FES has been widely researched for post-stroke lower limb rehabilitation; several systematic reviews [17, 18, 19] and national guidelines [20, 21] exist. Improvement in upper limb function is central to post-stroke rehabilitation as it positively affects ADL and quality of life . Yet, there is still a lack of clarity on the effectiveness of FES in post-stroke upper limb rehabilitation  despite systematic reviews having been undertaken [24, 25, 26, 27, 28]. In part, this is due to methodological limitations [27, 28] or the outdated nature of some existing reviews [24, 25, 26]. The latter was highlighted by a recent Cochrane overview of reviews calling for an up-to-date review and meta-analysis of randomised controlled trials (RCTs) related to electrical stimulation . A more recent systematic review found a significant improvement in motor outcomes with upper limb FES . However, this was based on a single meta-analysis that combined ADLs with upper limb-specific measures of functional motor ability, including studies where results were at risk of performance bias (intervention groups receiving greater duration of treatment than control groups) . Another found no improvement in motor function when FES was applied within 6 months of stroke . However, this predominantly included studies that applied electrical stimulation in the absence of volitional muscle contraction, confounding interpretation of the results. This inconsistency is reflected in the 2016 guidelines set by the Royal College of Physicians which recommends FES only in the context of clinical trials as an adjunct to conventional therapy .
This systematic review aims to elucidate the effectiveness of upper limb FES compared to standard therapy in improving ADL, in addition to motor outcomes, post-stroke. It represents an important addition to the literature that focuses on the use of volitional FES and, for the first time, distinguishes its effect on clinically relevant patient outcomes from surrogate markers of patient rehabilitation. This includes analyses based on patient sub-groups defined by the time after stroke at which FES was initiated.
Continue —> Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis | Systematic Reviews | Full Text
Activities of daily living, ADL, Functional electrical stimulation, Functional electrical stimulation (FES), meta-analysis, Motor function, Neurorehabilitation, Stroke, systematic review, UE, UL, Upper Extremity, upper limb