Effect of physical exercise on fear of falling in patients with stroke: A systematic review and meta-analysis.

OBJECTIVE: To consolidate the evidence on the effect of physical exercise on fear of falling in individuals with stroke. DATA SOURCES: PubMed, CINAHL, Cochrane Database and MEDLINE. METHODS: An extensive database search was conducted to identify the randomised controlled trials that examined the effect of physical exercise on fear of falling post-stroke. Grading of Recommendation, Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence for each meta-analysis. RESULTS: Fourteen trials totalling 1211 participants were included in this review. Thirteen of these (1180 participants) were included in the meta-analyses. In the primary analysis, very low-quality evidence suggested that exercise reduced fear of falling post-stroke (standardized mean difference (SMD) 0.48; 95% confidence interval (CI) 0.23 to 0.72). The effect was diminished at three- to six-month follow-up after exercise training ended (SMD -0.09; 95% CI -0.27 to 0.10; high-quality evidence). In the sensitivity analyses, the treatment effect was more pronounced in individuals with a lower baseline Berg balance score (BBS ≤45; SMD 0.53; 95%CI 0.17 to 0.88) and for those trials with exercise frequency of ≥3 sessions per week (SMD 0.70; 95%CI 0.39 to 1.01). Compared with circuit-based training consisting of a combination of walking, balance and strengthening exercises (SMD 0.27; 95% CI -0.09 to 0.63), walking programmes seemed to generate a larger effect on fear of falling (SMD 1.06; 95%CI 0.43 to 1.70). CONCLUSION: Physical exercise was beneficial for reducing fear of falling in individuals with stroke, particularly those with poorer balance ability.

Gait speed and spasticity are independently associated with estimated failure load in the distal tibia after stroke: an HR-pQCT study.

This HR-pQCT study was conducted to examine bone properties of the distal tibia post-stroke and to identify clinical outcomes that were associated with these properties at this site. It was found that spasticity and gait speed were independently associated with estimated failure load in individuals with chronic stroke. PURPOSE: (1) To examine the influence of stroke on distal tibia bone properties and (2) the association between these properties and clinical outcomes in people with chronic stroke. METHODS: Sixty-four people with stroke (age, 60.8 ± 7.7 years; time since stroke, 5.7 ± 3.9 years) and 64 controls (age: 59.4 ± 7.8 years) participated in this study. High-resolution peripheral quantitative computed tomography (HR-pQCT) was used to scan the bilateral distal tibia, and estimated failure load was calculated by automated finite element analysis. Echo intensity of the medial gastrocnemius muscle and blood flow of the popliteal artery were assessed with ultrasound. The 10-m walk test (10MWT), Fugl-Meyer Motor Assessment (FMA), and Composite Spasticity Scale (CSS) were also administered. RESULTS: The percent side-to-side difference (%SSD) in estimated failure load, cortical area, thickness, and volumetric bone mineral density (vBMD), and trabecular and total vBMD were significantly greater in the stroke group than their control counterparts (Cohen's d = 0.48-1.51). Isometric peak torque and echo intensity also showed significant within- and between-groups differences (p ≤ 0.01). Among HR-pQCT variables, the %SSD in estimated failure load was empirically chosen as one example of the strong discriminators between the stroke group and control group, after accounting for other relevant factors. The 10MWT and CSS subscale for ankle clonus remained significantly associated with the %SSD in estimated failure load after adjusting for other relevant factors (p ≤ 0.05). CONCLUSION: The paretic distal tibia showed more compromised vBMD, cortical area, cortical thickness, and estimated failure load than the non-paretic tibia. Gait speed and spasticity were independently associated with estimated failure load. As treatment programs focusing on these potentially modifiable stroke-related impairments are feasible to administer, future studies are needed to determine the efficacy of such intervention strategies for improving bone strength in individuals with chronic stroke.

Dual-Task Exercise Reduces Cognitive-Motor Interference in Walking and Falls After Stroke.

Background and Purpose- Functional community ambulation requires the ability to perform mobility and cognitive task simultaneously (dual-tasking). This single-blinded randomized controlled study aimed to examine the effects of dual-task exercise in chronic stroke patients. Methods- Eighty-four chronic stroke patients (24 women; age, 61.2±6.4 years; time since stroke onset, 75.3±64.9 months) with mild to moderate motor impairment (Chedoke-McMaster leg motor score: median, 5; interquartile range, 4-6) were randomly allocated to the dual-task balance/mobility training group, single-task balance/mobility group, or upper-limb exercise (control) group. Each group exercised for three 60-minute sessions per week for 8 weeks. The dual-task interference effect was measured for the time to completion of 3 mobility tests (forward walking, timed-up-and-go, and obstacle crossing) and for the correct response rate during serial-3-subtractions and verbal fluency task. Secondary outcomes included the Activities-specific Balance Confidence Scale, Frenchay Activities Index, and Stroke-specific Quality of Life Scale. The above outcomes were measured at baseline, immediately after, and 8 weeks after training. Fall incidence was recorded for a 6-month period posttraining. Results- Only the dual-task group exhibited reduced dual-task interference in walking time posttraining (forward walking combined with verbal fluency [9.5%, P=0.014], forward walking with serial-3-subtractions [9.6%, P=0.035], and the timed-up-and-go with verbal fluency [16.8%, P=0.001]). The improvements in dual-task walking were largely maintained at the 8-week follow-up. The dual-task cognitive performance showed no significant changes. The dual-task program reduced the risk of falls and injurious falls by 25.0% (95% CI, 3.1%-46.9%; P=0.037) and 22.2% (95% CI, 4.0%-38.4%; P=0.023), respectively, during the 6-month follow-up period compared with controls. There was no significant effect on other secondary outcomes ( P>0.05). Conclusions- The dual-task program was effective in improving dual-task mobility, reducing falls and fall-related injuries in ambulatory chronic stroke patients with intact cognition. It had no significant effect on activity participation or quality of life. Clinical trial registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02270398.

Non-pharmacological and pharmacological treatments for bone health after stroke: Systematic review with meta-analysis.

BACKGROUND: Hemi-osteoporosis is a common secondary complication of stroke. No systematic reviews of pharmacological and non-pharmacological agents for post-stroke bone health have estimated the magnitude and precision of effect sizes to guide better clinical practice. OBJECTIVES: To examine the benefits and harms of pharmacological and non-pharmacological agents on bone health in post-stroke individuals. METHODS: Eight databases were searched (PubMed, Cochrane library, Scopus, CINAHL Complete, Embase, PEDro, Clinicaltrils.gov and ICTRP) up to June 2023. Any controlled studies that applied physical exercise, supplements, or medications and measured bone-related outcomes in people with stroke were included. PEDro and the GRADE approach were used to examine the methodological quality of included articles and quality of evidence for outcomes. Effect sizes were calculated as standardized mean differences (SMD) and risk ratio (RR). Review Manager 5.4 was used for data synthetization. RESULTS: Twenty-four articles from 21 trials involving 22,500 participants (3,827 in 11 non-pharmacological and 18,673 in 10 pharmacological trials) were included. Eight trials were included in the meta-analysis. The methodological quality of half of the included non-pharmacological studies was either poor or fair, whereas it was good to excellent in 8 of 10 pharmacological studies. Meta-analysis revealed a beneficial effect of exercise on the bone mineral density (BMD) of the paretic hip (SMD: 0.50, 95 % CI: 0.16; 0.85; low-quality evidence). The effects of anti-resorptive medications on the BMD of the paretic hip were mixed and thus inconclusive (low-quality evidence). High-quality evidence showed that the administration of antidepressants increased the risk of fracture (RR: 2.36, 95 % CI 1.64-3.39). CONCLUSION: Exercise under supervision may be beneficial for hip bone health in post-stroke individuals. The effect of anti-resorptive medications on hip BMD is uncertain. The adverse effects of antidepressants on fracture risk among post-stroke individuals warrant further attention. Further high-quality studies are required to better understand this issue. REGISTRATION: PROSPERO CRD42022359186.

Effects of mechanical stimulation on mastectomy scars within 2 months of surgery: A single-center, single-blinded, randomized controlled trial.

BACKGROUND: One common complication after mastectomy is thickened scars at the surgical site that impair shoulder function. This study aimed to investigate the effects of mechanical stimulation on scar appearance, arm function, and quality of life of breast cancer survivors after mastectomy. METHODS: This was a single-center, single-blinded (assessor), randomized controlled trial with a 3-month follow-up. Women who had undergone mastectomy in the preceding 6 weeks for breast cancer were randomly allocated to an experimental group and a control group by permuted block randomization (block size=6). The experimental group received conventional treatment (mobilization and strengthening exercises) and mechanical stimulation applied to the mastectomy scar twice a week for 6 weeks (12 sessions). The control group received 12 sessions of conventional treatment only. Primary outcome measures included the Vancouver Scar scale (VSS) to assess scar quality. The secondary outcomes were spectrophotometry, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; shoulder range of motion; the Numeric Pain Rating scale; hand grip strength; and Functional Assessment of Chronic Illness Therapy-Breast Cancer (FACT-B). RESULTS: One hundred and eight participants were equally randomized to 2 groups. All follow-up assessments were completed in September 2018. Intention-to-treat analysis revealed a significant group × time interaction on the VSS (η² = 0.161, p < 0.001), DASH (η² = 0.060, p = 0.003), and FACT-B functional well-being scores (η² = 0.033, p = 0.034), indicating that the experimental group (n=54) showed greater improvement in these outcomes than the control group (n=54). Post-hoc analysis showed that the improvements in the VSS and DASH scores remained apparent at the 3-month follow-up. Other outcomes did not yield significant group × time interaction. No adverse effects were reported. CONCLUSION: The addition of mechanical stimulation to a conventional intervention program improved scar appearance, arm function, and functional well-being compared with conventional intervention alone.

Determinants of estimated failure load in the distal radius after stroke: An HR-pQCT study.

Bone health is often compromised after stroke and the distal radius is a common site of fragility fractures. The macro- and mircoproperties of bone tissue after stroke and their clinical correlates are understudied. The objectives of the study were to use High-Resolution peripheral Quantitative Computed Tomography (HR-pQCT) to investigate the bone properties at the distal radius, and to identify the correlates of estimated failure load for the distal radius in people with chronic stroke. This was a cross-sectional study of 64 people with stroke (age: 60.8 ± 7.7 years, stroke duration: 5.7 ± 3.9 years) and 64 age- and sex-matched controls. Bilateral bone structural, densitometric, geometric and strength parameters of the distal radius were measured using HR-pQCT. The architecture, stiffness and echo intensity of the bilateral biceps brachii muscle and brachial artery blood flow were evaluated using diagnostic ultrasound. Other outcomes included the Fugl-Meyer Motor Assessment (FMA), Motor Activity Log (MAL), and Composite Spasticity Scale (CSS). The results revealed a significant side (paretic vs non-paretic for the stroke group, non-dominant vs dominant for controls) by group (stroke vs control) interaction effect for estimated failure load, cortical area, cortical thickness, trabecular number and trabecular separation, and all volumetric density parameters. Post-hoc analysis showed percent side-to-side differences in bone outcomes were greater in the stroke group than the control group, with the exception of trabecular thickness and intracortical porosity. Among the HR-pQCT variables, percent side-to-side difference in trabecular volumetric bone mineral density contributed the most to the percent side-to-side difference in estimated failure load in the stroke group (R2 change = 0.334, ß = 1.106). Stroke-related impairments (FMA, MAL, CSS) were found to be significant determinants of the percent side-to-side difference in estimated failure load (R2 change = 0.233, ß = -0.480). This was the first study to examine bone microstructure post-stroke. We found that the paretic distal radius had compromised bone structural properties and lower estimated failure load compared to the non-paretic side. Motor impairment was a determinant of estimated bone strength at the distal radius and may be a potential intervention target for improving bone health post-stroke.

Minimal Clinically Important Difference of Four Commonly Used Balance Assessment Tools in Individuals after Total Knee Arthroplasty: A Prospective Cohort Study.

BACKGROUND: Although balance is commonly assessed during the recovery of total knee arthroplasty (TKA), the minimal clinically important difference (MCID) values of frequently used balance assessment tools have not been established previously in this population. OBJECTIVE: To determine the MCID of four balance tests-ie, the Balance Evaluation Systems Test (BESTest), Mini-BESTest, Brief-BESTest, and the Berg Balance Scale (BBS)-in individuals post-TKA. DESIGN: Prospective cohort. SETTING: Outpatient rehabilitation. PARTICIPANTS: Inclusion criteria: (1) first primary TKA with diagnosed knee osteoarthritis; (2) aged 50-85 years. EXCLUSION CRITERIA: (1) TKA due to rheumatoid arthritis of the knee or traumatic injury; (2) known medical conditions that influence balance ability. One hundred forty-six participants were recruited, and 134 of them with complete data were included in the analysis. INTERVENTIONS: Participants received individualized physiotherapy, consisting of electrotherapy for pain and edema control, mobilization and strengthening exercises, and gait and balance training, once or twice per week between assessments. MAIN OUTCOME MEASUREMENTS: Participants were assessed on the BESTest, Mini-BESTest, Brief-BESTest, BBS, and Functional Gait Assessment (FGA) 2 and 4 weeks after surgery. The FGA was used as the anchor reference measure to calculate the MCID of the other four balance tests. A distribution-based approach was also employed to derive the MCID (ie, standardized effect size of 0.5). RESULTS: The BESTest (area under curve [AUC] = 0.811, 95% confidence interval [CI] 0.739-0.883) had the highest accuracy in detecting clinically important improvements on the FGA (≥4 points), followed by the Mini-BESTest (AUC = 0.782, 95% CI 0.704-0.860), Brief-BESTest (AUC = 0.701, 95% CI 0.618-0.795), and BBS (AUC = 0.586, 95% CI 0.490-0.682). The anchor- and distribution-based MCIDs were 6-8 for the BESTest, 1-2 for the Mini-BESTest, and 2-3 for the Brief-BESTest. CONCLUSIONS: Improvements exceeding MCIDs established above are indicative of significant progress in balance function post-TKA. The BBS is not a recommended tool due to its low AUC value.