Examining Clinical Practice Guidelines for Exercise and Physical Activity as Part of Rehabilitation for People with Stroke: A Systematic Review.

BACKGROUND: Stroke is the leading cause of chronic physical disability in Western industrialised nations. Despite clear guidelines for exercise in individuals with many non-communicable diseases, the guidance for people with stroke (PwS) who frequently present with multiple comorbidities is less clear. A systematic review of exercise guidelines was undertaken to synthesise themes and patterns. METHODS: The review was completed according to the PRISMA statement. Guideline-specific databases were searched for worldwide clinical practice guidelines (CPGs). All included papers underwent quality assessment using the AGREE II protocol. Content synthesis and analysis of the guidelines was undertaken using CERT. RESULTS: Searching identified 2184 papers. After duplicate removal and screening by title and abstract, 22 CPGs remained for review. Seven guidelines identified three key roles for exercise interventions: (1) promoting a healthy lifestyle, (2) prevention of further strokes and (3) rehabilitation. Of concern, many CPGs fail to recommend appropriate safety measures and standards, pre-, during and post-exercise or tailor for specific needs. CONCLUSIONS: Global guidelines for exercise in PwS lack in-depth and technical information on the exercise delivery methods, application and dosage required to progress exercise interventions for PwS.

Using nominal group technique to advance power assisted exercise equipment for people with stroke.

BACKGROUND: Power assisted exercise is accessible and acceptable for people with stroke. The potential for technological advancement of the equipment to improve the user experience has been identified. Involvement of end users and service providers in the design of health technologies is essential in determining how said technology is perceived and adopted. This project invited people with stroke and service providers to influence design features and determine machine selection in the preliminary stages of a codesign research programme. AIMS: To capture the perspectives of people with stroke and professionals working with people with stroke about proposed digitalisation of power assisted exercise equipment and select machines for prototype development. METHODS: Nominal group technique was used to capture the perspectives, ideas, preferences and priorities of three stakeholder groups: people with stroke (n = 3, mean age 66 years), rehabilitation professionals (n = 3) and exercise scientists (n = 3). Two questions underpinned the structure of the events; 'What does an assistive exercise machine need to do to allow the person with stroke to engage in exercise?' and 'Which machines would you prioritise for use with People with Stroke?' Attendees were invited to cast votes to indicate their preferred machines. FINDINGS: Synthesis of the data from the NGT identified four domains; software and interface, exercise programme, machine and accessories, setting and service. Three preferred machines from a range of nine were identified through vote counting. CONCLUSION: Nominal group technique directed the selection of machines to be included in the development of the proposed technology. The vision shared by users during the structured discussion shaped the subsequent steps in the design and testing of the new technology. PATIENT AND SERVICE PROVIDER CONTRIBUTION: The opinions and preferences of people with stroke, rehabilitation professionals and exercise scientists were central to key decisions which will shape the digitalisation of power assisted equipment, influence future research and guide implementation of the new technologies.

Seated power assisted exercise machines assist different combinations of movement and can help people with stroke to take part in exercise programmes. Nine seated machines are manufactured in the UK. It was identified that the machines could be improved through development of technology to detect and display the user's physical effort during exercise. The research team successfully applied for funding to design and develop a new programme to display and measure user effort whilst exercising on the equipment. At the outset of the project the research team needed to make decisions about the capabilities of the new technology and select three machines from the range of nine to be prototyped. We used a method called nominal group technique during which end users with stroke, rehabilitation and exercise professionals were invited to structured meetings to share their ideas. At the end of the meetings the groups voted on their preferred machines. The ideas expressed during the meetings were listed and guided the ongoing development of the technology. The importance of a user-friendly interface was emphasised. The three machines which were allocated the most votes across the user groups were selected to be redesigned and developed with the new technology. The involvement of users at the outset of the design project ensured that they directly influenced the selection of machines and features of the new technology. Nominal group technique was an effective way of ensuring that all attendees had the opportunity to share their ideas and perspectives.

What Is Intensity and How Can It Benefit Exercise Intervention in People With Stroke? A Rapid Review.

Background: Stroke is one of the major causes of chronic physical disability in the United Kingdom, typically characterized by unilateral weakness and a loss of muscle power and movement coordination. When combined with pre-existing comorbidities such as cardiac disease and diabetes, it results in reductions in cardiovascular (CV) fitness, physical activity levels, functional capacity, and levels of independent living. High-intensity training protocols have shown promising improvements in fitness and function for people with stroke (PwS). However, it remains unclear how intensity is defined, measured, and prescribed in this population. Further, we do not know what the optimal outcome measures are to capture the benefits of intensive exercise. Aim: To understand how intensity is defined and calibrated in the stroke exercise literature to date and how the benefits of high-intensity training in PwS are measured. Methods: A rapid review of the literature was undertaken to provide an evidence synthesis that would provide more timely information for decision-making (compared with a standard systematic review). Electronic databases were searched (including Medline, PubMed, CINAHL, and Embase for studies from 2015 to 2020). These were screened by title and abstract for inclusion if they: (a) were specific to adult PwS; and (b) were high-intensity exercise interventions. Eligible studies were critically appraised using the Mixed Method Appraisal Tool (MMAT). The data extraction tool recorded the definition of intensity, methods used to measure and progress intensity within sessions, and the outcomes measure used to capture the effects of the exercise intervention. Results: Seventeen studies were selected for review, 15 primary research studies and two literature reviews. Sixteen of the 17 studies were of high quality. Nine of the primary research studies used bodyweight-supported treadmills to achieve the high-intensity training threshold, four used static exercise bikes, and two used isometric arm strengthening. Five of the primary research studies had the aim of increasing walking speed, five aimed to increase CV fitness, three aimed to improve electroencephalogram (EEG) measured cortical evoked potentials and corticospinal excitability, and two investigated any changes in muscle strength. Although only one study gave a clear definition of intensity, all studies clearly defined the high-intensity protocol used, with most (15 out of 17 studies) clearly describing threshold periods of high-intensity activity, followed by rest or active recovery periods (of varying times). All of the studies reviewed used outcomes specific to body structure and function (International Classification of Functioning, Disability, and Health (ICF) constructs), with fewer including outcomes relating to activity and only three outcomes relating to participation. The reported effect of high-intensity training on PwS was promising, however, the underlying impact on neurological, musculoskeletal, and CV systems was not clearly specified. Conclusions: There is a clear lack of definition and understanding about intensity and how thresholds of intensity in this population are used as an intervention. There is also an inconsistency about the most appropriate methods to assess and provide a training protocol based on that assessment. It remains unclear if high-intensity training impacts the desired body system, given the diverse presentation of PwS, from a neuromuscular, CV, functional, and psychosocial perspective. Future work needs to establish a clearer understanding of intensity and the impact of exercise training on multiple body systems in PwS. Further understanding into the appropriate assessment tools to enable appropriate prescription of intensity in exercise intervention is required. Outcomes need to capture measures specific not only to the body system, but also level of function and desired goals of individuals.

The effectiveness of group exercise for improving activity and participation in adult stroke survivors: a systematic review.

BACKGROUND: Following post stroke rehabilitation, group exercise interventions can be used to continue improving cardiovascular fitness, activity levels, balance, gait, movement efficiency, and strengthening. However, little is known of the effectiveness of group exercise for improving activity and participation in stroke survivors. OBJECTIVES: This review aims to assess the effectiveness of group exercise for improving activity and participation in adult stroke survivors. DATA SOURCES: Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library. STUDY ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) of group exercise using validated outcome measures of activity and participation for post stroke rehabilitation. Two independent reviewers assessed all abstracts, extracted data, conducted a narrative synthesis and assessed the quality of all included articles. The Cochrane Risk of Bias Tool assessed methodological quality and included outcome measure quality was assessed. RESULTS: 14 RCTs were included (n=624 chronic stroke survivors collectively). Studies ranged between 12 and 243 stroke participants with an average of left:right hemisphere lesions of 32:39 and average age was 66.7 years. Although intervention and control groups improved, no significant difference between group differences were evident. CONCLUSION: and implications of key findings: The review found improvements are short-term and less evident at long-term follow up with little improvements in participation after 6months. However, this review was limited to the standard of intervention reporting. Further research should consider consistency in measuring underpinning mechanisms of group exercise interventions, which may explain the lack of activity changes in long-term follow-up. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO: CRD42017078917.