R3-Walk and R6-Walk, Simple Clinical Equations to Accurately Predict Independent Walking at 3 and 6 Months After Stroke: A Prospective, Cohort Study.

OBJECTIVE: To investigate if independent walking at 3 and 6 months poststroke can be accurately predicted within the first 72 hours, based on simple clinical bedside tests. DESIGN: Prospective observational cohort study with 3-time measurements: immediately after stroke, and 3 and 6 months poststroke. SETTING: Public hospital. PARTICIPANTS: Adults with first-ever stroke evaluated at 3 (N=263) and 6 (N=212) months poststroke. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The outcome of interest was independent walking at 3 and 6 months after stroke. Predictors were age, walking ability, lower limb strength, motor recovery, spatial neglect, continence, and independence in activities of daily living. RESULTS: The equation for predicting walking 3 months poststroke was 3.040 + (0.283 × FAC baseline) + (0.021 × Modified Barthel Index), and for predicting walking 6 months poststroke was 3.644 + (-0.014 × age) + (0.014 × Modified Barthel Index). For walking ability 3 months after stroke, sensitivity was classified as high (91%; 95% CI: 81-96), specificity was moderate (57%; 95% CI: 45-69), positive predictive value was high (76%; 95% CI: 64-86), and negative predictive value was high (80%; 95% CI: 60-93). For walking ability 6 months after stroke, sensitivity was classified as moderate (54%; 95% CI: 47-61), specificity was high (81%; 95% CI: 61-92), positive predictive value was high (87%; 95% CI: 70-96), and negative predictive value was low (42%; 95% CI: 50-73). CONCLUSIONS: This study provided 2 simple equations that predict walking ability 3 and 6 months after stroke. This represents an important step to accurately identify individuals, who are at high risk of walking dependence early after stroke.

General and comparative self-rated health in chronic stroke: an important outcome measure for health professionals.

BACKGROUND: After a stroke, several aspects of health and function may influence how individuals perceive their own health. However, self-rated health (SRH), as well as its relationship with functioning, has been little explored in individuals with stroke. The aims of this study were to determine how individuals with chronic post-stroke disabilities evaluate their health, considering general, time- and age-comparative SRH questions and to investigate whether SRH measures would be influenced by the following health and functioning domains: mental/physical functions and personal factors. METHODS: Sixty-nine individuals with chronic post-stroke disabilities answered the three types of SRH questions and were assessed regarding depressive symptoms (emotional function domain), physical activity levels (physical function domain), and engagement in physical activity practice (personal factor domain). Subjects were divided into the following groups: good/poor for the general SRH question; better, similar, and "worse" for both time- and age-comparative questions. Between-group differences in the three domains for each SRH question were investigated (α = 5%). RESULTS: General SRH was rated as good by 73% of the participants. Time- and age-comparative SRH was rated as better by 36% and 47% and as similar by 31% and 28% of the subjects, respectively. Significant between-group differences in emotional function were found for both the general and age-comparative questions. For the time-comparative question, significant differences were only observed for physical function. CONCLUSION: SRH evaluation differed in individuals with chronic post-stroke disabilities according to the types of questions and health/functioning domains.

Reliability and validity of the incremental shuttle walking test in individuals after stroke.

BACKGROUND: There are limitations to perform the cardiopulmonary exercise test (CPET) and the six-minute walking test (6MWT) in clinical settings. The incremental shuttle walking test (ISWT) might be an alternative assessment of exercise capacity and an estimation of cardiopulmonary fitness after stroke. OBJECTIVES: To investigate the test-retest and inter-rater reliabilities, the standard error of measurement (SEM) and the minimal detectable change (MDC) of the ISWT, its construct validity to assess exercise capacity and its concurrent validity to estimate cardiopulmonary fitness after stroke. METHODS: Prospective diagnostic accuracy study. Fifty-one individuals (54 ± 11 years) at the chronic phase (65 ± 73 months after stroke) were included. The distance walked, in meters, during the 12-stage-ISWT and the 6MWT and the peak oxygen uptake (VO2peak, ml.kg-1.min-1) in the CPET (gold standard) were assessed. RESULTS: Significant and high to very high magnitude test-retest and inter-rater reliabilities (0.88≤ICC≤0.93) of the ISWT was found. The SEM for both reliabilities was small (-23.35 m≤ SEM≤41.47 m). The MDC for test-retest and inter-rater reliabilities were 114.63 m and 64.53 m, respectively. For construct validity, a significant and high magnitude correlation between the ISWT and the 6MWT was found (ICC = 0.82). For the concurrent validity, a significant, but low magnitude correlation was found between the ISWT and the VO2peak (rho = 0.42). CONCLUSIONS: The ISWT demonstrated adequate reliabilities and construct validity for exercise capacity assessment. However, the concurrent validity of the ISWT as an estimation of cardiopulmonary fitness still requires further research.

Efficacy of task-specific circuit training on physical activity levels and mobility of stroke patients: A randomized controlled trial.

BACKGROUND: Impaired mobility is related to low physical activity (PA) levels observed after stroke. Therapeutic approaches, such as task-specific circuit training (TSCT), used to improve mobility in individuals with stroke, could also improve PA levels. OBJECTIVE: To investigate the efficacy of TSCT, focused on both upper (UL) and lower (LL) limbs, in improving PA levels and mobility (primary outcomes), as well as muscle strength, exercise capacity, and quality of life (secondary outcomes) in subjects with stroke. METHODS: A randomized controlled trial with 36 subjects with chronic stroke was conducted. Experimental group: TSCT, involving both UL and LL. CONTROL GROUP: global stretching, memory exercises, and education sessions. Both groups received 60 minute sessions/week over 12 weeks. Outcomes were measured at baseline, post-intervention and 16 week follow-up. RESULTS: No changes were found for primary and secondary outcomes (0.11≤p≤0.99), except for quality of life, which improved in the experimental group post-intervention and 16 week follow-up (p = 0.02). CONCLUSION: TSCT focused on both UL and LL was not effective on PA levels and mobility of individuals with chronic stroke, however, improvements in quality of life were observed. Since this is the first study to investigate this combined training aimed at improving PA levels, future studies are necessary to better understand the impact of this type of intervention.

Aerobic Training Efficacy in Inflammation, Neurotrophins, and Function in Chronic Stroke Persons: A Randomized Controlled Trial Protocol.

BACKGROUND: Neuroinflammation is an important part of stroke pathophysiology and has both detrimental and beneficial effects after stroke. Besides that the enhancement of neurotrophins seems to be related to improvements in stroke recovery. Evidences suggest that exercise plays a role in modulating anti-inflammatory and neurotrophic effects. However, little is known about its impact in stroke survivors, mainly in chronic stroke. The purpose of this study is to investigate the efficacy of moderate-intensity treadmill exercise in changing inflammatory mediators, interleukin-6 (IL-6), soluble tumor necrosis factor receptors I and II (sTNFRI, sTNFRII), interleukin-10 (IL-10), and brain-derived neurotrophic factor (BDNF) levels in chronic stroke patients. The secondary objective is to investigate the effects of training in improve mobility and exercise capacity. METHODS: This is a randomized controlled trial. Chronic stroke patients will be randomized to an experimental or control group, and will receive group interventions three times per week, over 12 weeks. The experimental group will receive moderate-intensity (60%-80% of maximum heart rate reserve) treadmill exercise. Control group will perform walking training on the ground (<40% of maximum heart rate reserve). Primary outcomes include IL-6, sTNFRI, sTNFRII, IL-10, and BDNF levels. Secondary outcomes include mobility and exercise capacity. Outcomes will be measured at baseline, postintervention, and at the 4-week follow-up. DISCUSSION: The findings of this trial have the potential to provide important insights regarding the effects of an aerobic physical program in the inflammatory process and in the neuronal plasticity in stroke persons and its impact on mobility and exercise capacity.

A Single Trial May Be Used for Measuring Muscle Strength With Dynamometers in Individuals With Stroke: A Cross-Sectional Study.

BACKGROUND: The mean of 3 trials is commonly employed to report measures of muscle strength after a stroke. However, consistent and reliable results have been found for single trial dynamometric measures of grip, pinch, and trunk strength in individuals with stroke. Nevertheless, no studies were found that investigated whether only a single trial could be used for the assessment of the strength of both the upper and lower limb muscles. OBJECTIVE: To determine the best scoring method (one vs the means of 2 or 3 trials) to measure the strength of the upper and lower limb muscles in individuals with sub-acute and chronic stroke. DESIGN: Cross-sectional observational study. SETTING: Research laboratory, participants' homes, and community-based settings. PARTICIPANTS: Fifty-five individuals at the sub-acute (mean age: 61 ± 13 years; 3.7 ± 0.7 months poststroke) and 59 at the chronic poststroke phases (mean age: 57 ± 130 years; 90 ± 71 months poststroke). MAIN OUTCOME MEASUREMENTS: Bilateral maximum isometric strength measures of the shoulder, elbow, and wrist flexors/extensors; shoulder abductors; hip, knee, and ankle flexors/extensors; and hip abductors were obtained with a hand-held dynamometer. METHODS: After familiarization, 3 trials of maximal isometric strength were obtained for all evaluated muscle groups. One-way analysis of variance was used to compare the results obtained with the first vs the means of 2 and 3 trials for all the assessed muscle groups. RESULTS: The values provided by the different scoring methods were similar for all evaluated muscle groups in individuals with sub-acute (.68 ≤ P ≤ .99) and chronic (.69 ≤ P ≤ .99) stroke. CONCLUSIONS: A single trial, after familiarization, may be used for measuring the strength of the upper and lower limb muscles with hand-held dynamometers in individuals with sub-acute and chronic stroke. This increases the clinical applicability of hand-held dynamometers for strength measurement, as it reduces the assessment burden placed on the participants and therapists. LEVEL OF EVIDENCE: III.

Validity and reliability of the modified sphygmomanometer test to assess strength of the lower limbs and trunk muscles after stroke.

OBJECTIVES: To investigate the criterion-related validity, test-retest and inter-rater reliabilities of the modified sphygmomanometer test (MST) for assessment of the strength of the trunk and lower limb muscles in subjects with chronic stroke, and to verify whether the number of trials affected the results. PATIENTS AND METHODS: Fifty-nine subjects with stroke (mean age 57.80 years; standard deviation 13.79 years) were included in the study. Maximum isometric strength was assessed with a hand-held dynamometer and the MST. To investigate whether the number of trials affected the results, one-way analysis of variance was applied. For the criterion-related validity, test-retest and inter-rater reliabilities of the MST, Pearson correlation coefficients, coefficients of determination, and intra-class correlation coefficient (ICC) were calculated. RESULTS: Different numbers of trials provided similar values for all assessed muscles (0.003 ≤ F ≤ 0.08; 0.92 ≤ p ≤ 1.00) with adequate validity (0.79 ≤ r ≤ 0.90; p ≤ 0.001), test-retest (0.57 ≤ ICC ≤ 0.98; p ≤ 0.001), and inter-rater reliabilities (0.53 ≤ ICC ≤ 0.97; p ≤ 0.001), except for the inter-rater reliability of the non-paretic ankle plantar flexors. The values obtained with the MST were good predictors of those obtained with the hand-held dynamometer (0.57 ≤ r2 ≤ 0.79). CONCLUSION: In general, the MST showed adequate criterion-related validity, test-retest and inter-rater reliabilities for the assessment of strength of the lower limb and trunk muscles in subjects with chronic stroke. For the majority of the assessed muscles, only one trial, after familiarization, provided adequate strength values.

Muscular activation patterns during active prone hip extension exercises.

BACKGROUND: Changes in activation patterns of hip extensors and pelvic stabilizing muscles are recognized as factors that cause low back disorders and these disturbances could have an impact on the physiological loading and alter the direction and magnitude of joint reaction forces. OBJECTIVE: To investigate activation patterns of the gluteus maximus, semitendinosus and erector spinae muscles with healthy young individuals during four different modalities of therapeutic exercise. METHODS: Thirty-one volunteers were selected: (16 men and 15 women), age (24.5+/-3.47years), body mass of 66.89+/-11.89kg and a height of 1.70+/-0.09m). They performed four modalities of therapeutic exercise while the electromyographic activity of the investigated muscles was recorded to determine muscle pattern activation for each exercise. RESULTS: Repeated measure ANOVA revealed that muscle activation patterns were similar for the four analyzed exercises, starting with the semitendinosus, followed by the erector spinae, and then, the gluteus maximus. The gluteus maximus was the last activated muscle during hip extension associated with knee flexion (p<0.0001), knee extension (p<0.0001), and with lateral rotation and knee flexion (p<0.05). CONCLUSION: Findings of the present study suggested that despite individual variability, the muscle firing order was similar for the four therapeutic exercises.

Scapular muscular activity with shoulder impingement syndrome during lowering of the arms.

OBJECTIVE: To compare isolated electromyographic (EMG) activity of the serratus anterior, upper, middle, and lower trapezius, as well as the coactivation of the upper and middle trapezius/serratus anterior in subjects with and without shoulder impingement syndrome (IS), during lowering of the arms. DESIGN: Cross-sectional study. SETTING: University laboratory. PARTICIPANTS: Twenty young adults, 10 with unilateral IS degree I or II (mean age 28.6 +/- 5.89 years) and 10 without any complaints or history of previous shoulder lesions (mean age 29.0 +/- 5.35 years), matched by gender, age, and levels of physical activity. MAIN OUTCOME MEASUREMENTS: Isolated EMG activity of the serratus anterior, upper, middle, and lower trapezius, as well as the coactivation of the upper trapezius and middle trapezius/serratus anterior. The EMG activity was quantified by root mean square calculations and normalized by maximal voluntary isometric contractions. RESULTS: Significant differences between groups were found only for the coactivation of the middle trapezius/serratus anterior (F = 6.81; P = 0.02). No significant differences were found between sides (F = 0.05; P = 0.83) nor for interactions between sides and groups (F = 3.85; P = 0.07). CONCLUSIONS: These findings pointed out the importance of evaluating the lowering of the arms in individuals with IS and suggested that measures of coactivation, besides reflecting the real purpose of the muscular actions during functional activities, are more sensitive to detect changes between groups. The evaluation of the coactivation of the middle trapezius/serratus anterior should be included in clinical assessment of individuals with IS and investigations on the etiology and progression of IS.