Cardiovascular conditioning for comfortable gait speed and total distance walked during the chronic stage of stroke: a meta-analysis.

OBJECTIVE: To examine the effectiveness of cardiovascular conditioning on comfortable gait speed and total distance walked when initiated in the chronic stage of stroke through a meta-analysis. METHODS: MEDLINE, CINAHL, EMBASE, and Scopus databases were searched from 1980 to June 2012. A study was selected if (1) it was a randomized controlled trial; (2) individuals in the study were entered into the study at or over 6 months post stroke; (3) cardiorespiratory training was initiated during the chronic stage of stroke; and (4) study participants were ≥18 years of age. A standardized mean difference (SMD ± SE and 95% confidence interval [CI]) was calculated for comfortable gait speed and/or 6-minute walk test (6MWT). results from all studies were then pooled using a random effects model. Treatment effect sizes were interpreted as small, ≯0.2; moderate, ≯0.5; or large, ≯0.8. Methodological quality of studies was assessed using the Physiotherapy Evidence Database (PEDro) tool. RESULTS: Seven studies met inclusion criteria. The analysis demonstrated a moderate and significant effect on 6MWT post treatment (SMD = 0.581 ± 0.277; 95% CI, -0.037 to 1.125; P = .036) with an improvement of 111.4 m to a pooled average of 357.7 m. No significant improvement in comfortable gait speed was noted post treatment (SMD = 0.159 ± 0.124; 95% CI, -0.085 to 0.402; P = .202) or at follow-up (SMD = 0.248 ± 0.256; 95% CI, -0.253 to 0.750; P = .332). CONCLUSION: Cardiovascular conditioning resulted in clinically relevant gains in walking distance of over 100 m post treatment on the 6MWT when initiated during the chronic stage of stroke. These results demonstrate that individuals in the chronic stage of stroke can still benefit from interventions to improve gait and mobility. This has important implications for outpatient and community-based programs.

Functional electrical stimulation for improving gait in persons with chronic stroke.

BACKGROUND: The long-term management of stroke is an area of increasing clinical interest, and it is important to identify therapeutic interventions that are effective in the chronic phase post stroke. OBJECTIVE: To conduct a systematic review on the effectiveness of functional electrical stimulation (FES) in improving lower extremity function in chronic stroke. METHODS: Multiple databases (PubMed, CINAHL, EMBASE, and Scopus) were searched for relevant articles. Studies were included for review if (1) ≥50% of the study population has sustained a stroke, (2) the study design was a randomized controlled trial (RCT), (3) the mean time since stroke was ≥6 months, (4) FES or neuromuscular electrical stimulation (NMES) was compared to other interventions or a control group, and (5) functional lower extremity outcomes were assessed. Methodological quality was assessed using the PEDro tool. A standardized mean difference (SMD ± SE and 95% confidence interval [CI]) was calculated for the 6-minute walk test (6MWT). Pooled analysis was conducted for treatment effect of FES on the 6MWT distance using a fixed effects model. RESULTS: Seven RCTs (PEDro scores 5-7) including a pooled sample size of 231 participants met inclusion criteria. Pooled analysis revealed a small but significant treatment effect of FES (0.379 ± 0.152; 95% CI, 0.081 to 0.677; P = .013) on 6MWT distance. CONCLUSION: FES may be an effective intervention in the chronic phase post stroke. However, its therapeutic value in improving lower extremity function and superiority over other gait training approaches remains unclear.

Time to rethink long-term rehabilitation management of stroke patients.

BACKGROUND: It has long been assumed that stroke patients plateau in their recovery within 3 to 6 months of their stroke, and evidence for rehabilitation during the chronic stage is limited. As a consequence, rehabilitation resources for the management of chronic stroke are minimal. OBJECTIVE: The primary objective was to identify randomized controlled trials (RCTs) across the continuum of stroke rehabilitation for interventions initiated 6 months or more following the onset of stroke. The secondary objective was to determine whether treatments provided post 6 moths are effective in improving outcomes among stroke survivors. METHODS: Multiple databases were used to identify all RCTs published from 1970 to June 2012 in English language where the stroke interventions were initiated more than 6 months after the onset of the stroke. Data abstraction was performed using standardized data abstraction form that included general citation information, study participant characteristics, methodology, outcomes accessed, and overall findings. RESULTS: The results of our analysis revealed 339 RCTs. The mean number of subjects per study was 73. Two hundred fifty-six RCTs were related to motor recovery, 39 to cognitive function, and only 19 to psychosocial issues and community reintegration. The majority of the RCT s demonstrated a significant positive benefit. CONCLUSIONS: There is a robust evidence-base for stroke rehabilitation interventions in chronic stroke. This research synthesis reveals a paradox, whereby an impressive evidence-base contrasts with the limited optimism and resources available for rehabilitation in chronic stroke.