Prediction of Independent Walking in People Who Are Nonambulatory Early After Stroke: A Systematic Review.

Background and Purpose: One systematic review has examined factors that predict walking outcome at one month in initially nonambulatory patients after stroke. The purpose of this systematic review was to examine, in nonambulatory people within a month of stroke, which factors predict independent walking at 3, 6, and 12 months. Methods: Prognostic factors: Any factors measured within one month after stroke with the aim of predicting independent walking. Outcome of interest: Independent walking defined as walking with or without an aid but with no human assistance. Results: Fifteen studies comprising 2344 nonambulatory participants after stroke were included. Risk of bias was low in 7 studies and moderate in 8 studies. Individual meta-analyses of 2 to 4 studies were performed to calculate the pooled estimate of the odds ratio for 12 prognostic factors. Younger age (odds ratio [OR], 3.4, P<0.001), an intact corticospinal tract (OR, 8.3, P<0.001), good leg strength (OR, 5.0, P<0.001), no cognitive impairment (OR, 3.5, P<0.001), no neglect (OR, 2.4, P=0.006), continence (OR, 2.3, P<0.001), good sitting (OR, 7.9, P<0.001), and independence in activities of daily living (OR 10.5, P<0.001) predicted independent walking at 3 months. Younger age (OR, 2.1, P<0.001), continence (OR, 13.8, P<0.001), and good sitting (OR, 19.1, P<0.001) predicted independent walking at 6 months. There were insufficient data at 12 months. Conclusions: Younger age, an intact corticospinal tract, good leg strength, continence, no cognitive impairment, no neglect, good sitting, and independence in activities of daily living in patients who are nonambulatory early after stroke predict independent walking at 3 months. REGISTRATION: URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42018108794.

Promoting physical activity after stroke via self-management: a feasibility study.

BACKGROUND: Many people with mild disability after stroke are physically inactive despite the risk of recurrent stroke. A self-management program may be one strategy to increase physical activity in stroke survivors. OBJECTIVES: To investigate the feasibility of a self-management program, and determine whether self-management can increase daily physical activity levels and self-efficacy for exercise, decrease cardiovascular risk, and improve walking ability, participation, and quality of life in people with mild disability after stroke. METHOD: A Phase I, single-group, pre-post intervention study was carried out with twenty stroke survivors who had mild disability and were discharged directly home from acute stroke units. A self-management program was delivered via five home-based sessions over 3 months, incorporating: education, goal setting, barrier identification, self-monitoring, and feedback. Feasibility of the intervention was determined by examining adherence, duration, usefulness, and safety. Clinical outcomes were amount of physical activity (duration of moderate physical activity in min/day and counts of physical activity in steps/day), self-efficacy, cardiovascular risk, walking ability, participation, and quality of life. RESULTS: The intervention was feasible with 96% of sessions being delivered, each taking less than an hour (41 min, SD 12). Participants perceived the self-management program to be useful and there were few adverse events. At 3 months, participants completed 27 min/day (95% CI 4-49) more moderate physical activity than at baseline and 16 min/day (95% CI -10 to 42) at 6 months. CONCLUSION: Self-management appears to be feasible and has the potential to increase physical activity in people with mild disability after stroke. A Phase II randomized trial is warranted.

Lap-tray and triangular sling are no more effective than a hemi-sling in preventing shoulder subluxation in those at risk early after stroke: a randomized trial.

BACKGROUND: Shoulder subluxation is a common secondary impairment of the upper limb following stroke. A range of supportive devices are used in rehabilitation to prevent shoulder subluxation, including hemi-slings and firm supports, such as arm troughs, however, there is little evidence regarding their efficacy. AIM: To determine whether a modified lap-tray during sitting and a triangular sling during standing is more effective than a hemi-sling in preventing shoulder subluxation, pain, contracture and upper limb activity limitation after stroke. DESIGN: A prospective, randomized trial with concealed allocation, assessor blinding and intention-to-treat analysis. SETTING: Three inpatient rehabilitation units in Australia and Norway. POPULATION: Forty-six acute stroke survivors within 3 weeks of stroke who were at risk of subluxation. METHODS: The experimental group used a modified lap-tray while sitting and a triangular sling while standing to support the affected arm for four weeks. The control group used a hemi-sling while sitting and standing. The primary outcome was amount of shoulder subluxation on X-ray. Secondary outcomes were upper limb activity, pain and contracture. RESULTS: There was no significant difference between groups in terms of shoulder subluxation (MD -3 mm, 95% CI -8 to 3). There was a trend for the experimental group to develop less pain at rest (MD -0.7 out of 10, 95% CI -2.2 to 0.8) and during shoulder external rotation (MD -1.7 out of 10, 95% CI -3.7 to 0.3) and a trend towards having less contracture of shoulder external rotation (MD -10 deg, 95% CI -22 to 2). There was no significant difference between groups in terms of other contractures and activity of the upper limb. CONCLUSIONS: A lap-tray during sitting combined with a triangular sling during standing is no more effective than a hemi-sling in preventing subluxation, pain, contracture and activity limitation in acute stroke survivors at risk of shoulder subluxation. CLINICAL REHABILITATION IMPACT: The use of a lap-tray during sitting and triangular sling during standing is not indicated as an alternative to the hemi-sling to prevent shoulder subluxation in patients after stroke, so alternative strategies with proven efficacy, such as electrical stimulation, should be considered.

Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke: a systematic review.

QUESTION: Is biofeedback during the practice of lower limb activities after stroke more effective than usual therapy in improving those activities, and are any benefits maintained beyond the intervention? DESIGN: Systematic review with meta-analysis of randomised trials with a PEDro score > 4. PARTICIPANTS: People who have had a stroke. INTERVENTION: Biofeedback (any type delivered by any signal or sense) delivered concurrently during practice of sitting, standing up, standing or walking compared with the same amount of practice without biofeedback. OUTCOME MEASURES: Measures of activity congruent with the activity trained. RESULTS: Eighteen trials including 429 participants met the inclusion criteria. The quality of the included trials was moderately high, with a mean PEDro score of 6.2 out of 10. The pooled effect size was calculated as a standardised mean difference (SMD) because different outcome measures were used. Biofeedback improved performance of activities more than usual therapy (SMD 0.50, 95% CI 0.30 to 0.70). CONCLUSION: Biofeedback is more effective than usual therapy in improving performance of activities. Further research is required to determine the long-term effect on learning. Given that many biofeedback machines are relatively inexpensive, biofeedback could be utilised widely in clinical practice. [Stanton R, Ada L, Dean CM, Preston E (2016) Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke: a systematic review.Journal of Physiotherapy63: 11-16].

Effect of information feedback on training standing up following stroke: a pilot feasibility study.

BACKGROUND AND OBJECTIVE: The ability to stand up is reduced following stroke. Traditional biofeedback is effective in improving the performance of lower limb activities. The aim of this study was to investigate the feasibility of and potential for information feedback from a simple inexpensive device to improve the ability to stand up from a chair in people following stroke. METHODS: A single-group study with pre-post measures design was used. Twenty people with hemiplegic stroke in inpatient rehabilitation received 10 sessions over 2 weeks of information feedback about foot placement during training of standing up. Progression involved increasing repetitions, increasing difficulty and fading feedback. Feasibility was determined by adherence, time taken, acceptability and safety. Clinical outcomes were the time taken to stand up, quality and foot position measured using the 5-Times-Sit-To-Stand-Test and carryover into daily activities measured by covert observation. RESULTS: The study was feasible with 97% of sessions completed, taking 19 (SD 6) to 25 (SD 10) minutes. Participants understood (4.6/5), found useful (4.6/5), challenging (4.4/5) and would recommend (4.7/5) the training. The time to stand up 5 times decreased by 24 (95% CI -48 to -1) s, and the quality of standing improved by 1.0/10.0 (95% CI 0.2 to 1.8). Carryover of the correct foot placement occurred to real life, with the beginning foot position correct 2.1/3.0 (95% CI 1.6 to 2.6) and end foot position correct 1.8/3.0 (95% CI 1.2 to 2.4) occasions. CONCLUSIONS: The training is feasible and has the potential to improve the ability to stand up.

Feedback Received While Practicing Everyday Activities During Rehabilitation After Stroke: An Observational Study.

BACKGROUND AND PURPOSE: The provision of feedback is important for effective skill learning. The purpose of this study was to examine the nature of feedback provided during the practice of everyday activities (such as standing up, walking, and reaching and grasping objects) during stroke rehabilitation, both when the therapist was present and when the patient was practicing alone. DESIGN: A cross-sectional observational study of the feedback received during rehabilitation by people who had had a stroke was conducted. Forty unique patient-therapist dyads were observed during 30 minutes of actual practice of everyday activities with data collected through behavioural mapping. The following was recorded: the activity practiced, whether the therapist was present, whether feedback was provided verbally or by equipment, and the content of feedback. PARTICIPANTS: A sample of all therapists providing rehabilitation within one Australian health service and their patients who had had a stroke. MEASURES: Quantity, frequency, mode (verbal or equipment) and content (information feedback, motivational statements, unrelated or none) of feedback during the practice of everyday activities were determined. RESULTS: For 68% of the time that patients were practicing activities, they received ≥1 occasion of feedback/minute. When the therapist was present, the frequency of motivational statements was more than four times greater, at 1.32 (SD 0.6) occasions/minute, than information feedback. For 25% of the time, the therapist was not present, and no feedback was provided. CONCLUSION: Given the importance of specific content for learning, therapists could replace some motivational statements with information feedback. When practicing alone, information feedback could be provided by commercially available biofeedback or customized equipment.

The Physiotherapy eSkills Training Online resource improves performance of practical skills: a controlled trial.

BACKGROUND: E-learning is a common and popular mode of educational delivery, but little is known about its effectiveness in teaching practical skills. The aim of this study was to determine whether the Physiotherapy eSkills Training Online resource in addition to usual teaching improved the performance of practical skills in physiotherapy students. METHOD: This study was a non-randomised controlled trial. The participants were graduate entry physiotherapy students enrolled in consecutive semesters of a neurological physiotherapy unit of study. The experimental group received the Physiotherapy eSkills Training Online resource as well as usual teaching. The Physiotherapy eSkills Training Online resource is an online resource incorporating (i) video-clips of patient-therapist simulations; (ii) supportive text describing the aim, rationale, equipment, key points, common errors and methods of progression; and (iii) a downloadable PDF document incorporating the online text information and a still image of the video-clip for each practical skill. The control group received usual teaching only. The primary outcomes were the overall performance of practical skills as well as their individual components, measured using a practical examination. RESULTS: The implementation of the Physiotherapy eSkills Training Online resource resulted in an increase of 1.6 out of 25 (95% CI -0.1 to 3.3) in the experimental group compared with the control group. In addition, the experimental group scored 0.5 points out of 4 (95% CI 0 to 1.1) higher than the control group for 'effectiveness of the practical skill' and 0.6 points out of 4 (95% CI 0.1 to 1.1) higher for 'rationale for the practical skill'. CONCLUSION: There was improvement in performance of practical skills in students who had access to the Physiotherapy eSkills Training Online resource in addition to usual teaching. Students considered the resource to be very useful for learning.

What is the probability of patients who are nonambulatory after stroke regaining independent walking? A systematic review.

Patients after stroke who are nonambulatory require resources, and independent walking becomes a major determinant of the ability to participate in activities of daily living. Our objective was to determine the probability of walking for patients who are nonambulatory in the first month after stroke. We performed a systematic review and meta-analysis of consecutive, prospective studies of nonambulatory patients within the first month after stroke in rehabilitation and acute units. The outcomes were the probability of achieving independent walking at three-, six- and 12 months after stroke. Twenty-six studies were included in the review. Seventeen studies comprising 2856 participants were entered into meta-analyses. For initially nonambulatory stroke patients managed in a rehabilitation unit, the probability of independent walking was 0.60 (95% CI 0.47-0.74, 1373 participants) at three-months, 0.65 (95% CI 0.53-0.77, 444 participants) at six-months and 0.91 (95% CI 0.81-1.00, 24 participants) at 12 months. For patients managed in an acute unit, the probability of independent walking was 0.39 (95% CI 0.27-0.52, 634 participants) at three-months, 0.69 (95% CI 0.46-0.92, 405 participants) at six-months and 0.74 (95% CI 0.59-0.88, 34 participants) at 12 months. 60% of patients managed in a rehabilitation unit who are nonambulatory in the first month after stroke will regain independent walking compared with 39% of those managed in an acute unit. This information can be used clinically to make decisions about allocation of rehabilitation resources, education of patients and carers, and for discharge planning.

Biofeedback improves activities of the lower limb after stroke: a systematic review.

QUESTION: Is biofeedback during the practice of lower limb activities after stroke effective in improving performance of those activities, and are any benefits maintained after intervention ceases? DESIGN: Systematic review with meta-analysis of randomised trials. PARTICIPANTS: People who have had a stroke. INTERVENTION: Biofeedback during practice of sitting, standing up, standing, or walking. OUTCOME MEASURES: Continuous measures of activity congruent with the activity trained. RESULTS: 22 trials met the inclusion criteria and 19 contained data suitable for analysis. Effect sizes were calculated as standardised mean differences because different outcome measures were used. Since inclusion of all trials produced substantial statistical heterogeneity, only trials with a PEDro score >4 (11 trials) were included in the final analysis (mean PEDro score 5.7). In the short-term, biofeedback improved lower limb activities compared with usual therapy/placebo (SMD=0.49, 95% CI 0.22 to 0.75). Lower limb activities were still improved compared with usual therapy/placebo 1 to 5 months after the cessation of intervention (SMD=0.41, 95% CI 0.06 to 0.75). CONCLUSION: Augmenting feedback through the use of biofeedback is superior to usual therapy/placebo at improving lower limb activities in people following stroke. Furthermore, these benefits are largely maintained in the longer term. Given that many biofeedback machines are relatively inexpensive, biofeedback could be utilised more widely in clinical practice.