Effects of Exercise Therapy on Balance Capacity in Chronic Stroke: Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: The purpose of this systematic review and meta-analysis was to investigate the effects of exercise training on balance capacity in people in the chronic phase after stroke. Furthermore, we aimed to identify which training regimen was most effective. METHODS: Electronic databases were searched for randomized controlled trials evaluating the effects of exercise therapy on balance capacity in the chronic phase after stroke. Studies were included if they were of moderate or high methodological quality (PEDro score ≥4). Data were pooled if a specific outcome measure was reported in at least 3 randomized controlled trials. A sensitivity analysis and consequent subgroup analyses were performed for the different types of experimental training (balance and/or weight-shifting training, gait training, multisensory training, high-intensity aerobic exercise training, and other training programs). RESULTS: Forty-three randomized controlled trials out of 369 unique hits were included. A meta-analysis could be conducted for the Berg Balance Scale (28 studies, n=985), Functional Reach Test (5 studies, n=153), Sensory Organization Test (4 studies, n=173), and mean postural sway velocity (3 studies, n=89). A significant overall difference in favor of the intervention group was found for the Berg Balance Scale (mean difference 2.22 points (+3.9%); 95% confidence interval [CI], 1.26-3.17; P<0.01; I(2)=52%), Functional Reach Test (mean difference=3.12 cm; 95% CI, 0.90-5.35; P<0.01; I(2)=74%), and Sensory Organization Test (mean difference=6.77 (+7%) points; 95% CI, 0.83-12.7; P=0.03; I(2)=0%). Subgroup analyses of the studies that included Berg Balance Scale outcomes demonstrated a significant improvement after balance and/or weight-shifting training of 3.75 points (+6.7%; 95% CI, 1.71-5.78; P<0.01; I(2)=52%) and after gait training of 2.26 points (+4.0%; 95% CI, 0.94-3.58; P<0.01; I(2)=21, whereas no significant effects were found for other training regimens. CONCLUSIONS: This systematic review and meta-analysis showed that balance capacities can be improved by well-targeted exercise therapy programs in the chronic phase after stroke. Specifically, balance and/or weight-shifting and gait training were identified as successful training regimens.

Improved gait adjustments after gait adaptability training are associated with reduced attentional demands in persons with stroke.

After stroke, the ability to make step adjustments during walking is reduced and requires more attention, which may cause problems during community walking. The C-Mill is an innovative treadmill augmented with visual context (e.g., obstacles and stepping targets), which was designed specifically to practice gait adaptability. The objective of this study was to determine whether C-Mill gait adaptability training can help to improve gait adjustments and associated attentional demands. Sixteen community-ambulating persons in the chronic stage of stroke (age: 54.8 ± 10.8 years) received ten sessions of C-Mill training within 5-6 weeks. Prior to and after the intervention period, participants performed an obstacle-avoidance task with and without a secondary attention-demanding auditory Stroop task to assess their ability to make gait adjustments (i.e., obstacle-avoidance success rates) as well as the associated attentional demands (i.e., Stroop success rates, stratified for pre-crossing, crossing, and post-crossing strides). Obstacle-avoidance success rates improved after C-Mill training from 52.4 ± 16.3 % at pretest to 77.0 ± 16.4 % at posttest (p < 0.001). This improvement was accompanied by greater Stroop success rates during the obstacle-crossing stride only (pretest: 62.9 ± 24.9 %, posttest: 77.5 ± 20.4 %, p = 0.006). The observed improvements in obstacle-avoidance success rates and Stroop success rates were strongly correlated (r = 0.68, p = 0.015). The ability to make gait adjustments and the associated attentional demands can be successfully targeted in persons with stroke using C-Mill training, which suggests that its underlying assumptions regarding motor control are appropriate. This study lends support and guidance for designing a randomized controlled trial to further examine the potential of C-Mill training for improving safe community ambulation after stroke.

Self-management program improves participation in patients with neuromuscular disease: A randomized controlled trial.

OBJECTIVE: To investigate the effectiveness of Energetic, a self-management group program combining aerobic training, energy conservation management, and relapse prevention to improve social participation in patients with neuromuscular disease (NMD) and chronic fatigue. METHODS: In this multicenter, assessor-blinded, 2-armed randomized controlled trial with repeated measurements, 53 patients with various types of NMD and chronic fatigue were randomly allocated to Energetic, a 4-month group intervention, or to usual care. The primary endpoint was social participation assessed with the Canadian Occupational Performance Measure (COPM) performance scale immediately postintervention. Secondary outcomes included COPM satisfaction scale, 6-Minute Walk Test (6MWT), and Checklist Individual Strength-subscale fatigue. Participants were followed for 11 months postintervention. Data were analyzed with linear models that account for repeated measurements. RESULTS: Directly after intervention, the mean group difference for COPM-performance was 1.7 (95% confidence interval [CI] 1.0-2.4; p < 0.0001) in favor of the intervention group (n = 29), adjusted for baseline, sex, diagnosis, and work status. This effect was retained at 11 months follow-up (0.9; 95% CI 0.0-1.7; p = 0.049). The COPM satisfaction scale and 6MWT improved more in the intervention group compared to usual care. After 3 and 11 months follow-up, most beneficial effects on social participation and functional endurance were retained. CONCLUSION: Energetic led to sustainable improvements in social participation and functional endurance compared to usual care in patients with NMD and chronic fatigue.Clinicaltrials.gov IDENTIFIER: NCT02208687. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that a combination of aerobic training, energy conservation management, and relapse prevention improves social participation in patients with NMD and chronic fatigue.

Gait adaptability training improves obstacle avoidance and dynamic stability in patients with cerebellar degeneration.

Balance and gait problems in patients with cerebellar degeneration lead to reduced mobility, loss of independence, and frequent falls. It is currently unclear, however, whether balance and gait capacities can be improved by training in this group of patients. Therefore, the aim of this study was to examine the effects of gait adaptability training on obstacle avoidance and dynamic stability during adaptive gait. Ten patients with degenerative cerebellar ataxia received 10 protocolized gait adaptability training sessions of 1 h each during 5 weeks. Training was performed on a treadmill with visual stepping targets and obstacles projected on the belt's surface. As the primary outcome, we used an obstacle avoidance task while walking on a treadmill. We determined avoidance success rates, as well as dynamic stability during the avoidance manoeuvre. Clinical ratings included the scale for the assessment of ataxia (SARA), 10 m walking test, timed up-and-go test, berg balance scale, and the obstacle subtask of the emory functional ambulation profile (EFAP). Following the intervention, success rates on the obstacle avoidance task had significantly improved compared to pre-intervention. For successful avoidance, participants allowed themselves smaller stability margins in the sagittal plane in the (shortened) pre-crossing step. However, in the subsequent steps they returned to baseline stability values more effectively than before training. SARA scores and the EFAP obstacle subtask improved significantly as well. This pilot study provides preliminary evidence of a beneficial effect of gait adaptability training on obstacle avoidance capacity and dynamic stability in patients with cerebellar degeneration.

Step by step: a proof of concept study of C-Mill gait adaptability training in the chronic phase after stroke.

OBJECTIVE: To evaluate the concept of C-Mill gait adaptability training. DESIGN: Pre- and post-intervention assessments. SUBJECTS: Sixteen community-dwelling persons in the chronic phase after stroke (mean age 54.8 years). METHODS: Participants received 10 sessions (1 h per session, for 5-6 weeks) of gait adaptability training on an instrumented treadmill augmented with visual targets and obstacles (C-Mill). Pre- and post-intervention assessments included: (i) clinical assessments of balance and gait: 10-m walking test, Timed Up-and-Go test, Berg Balance Scale, obstacle sub-task of the Emory Functional Ambulation Profile, and the Trunk Impairment Scale; (ii) physical activity level, assessed with a pedometer; (iii) success rate of accurate step adjustments towards a displacing target, assessed with an instrumented Target-Stepping Task; (iv) participant's experience with the training. RESULTS: All clinical assessments improved significantly after training (all p < 0.05), except for the Trunk Impairment Scale (p = 0.584). Physical activity increased by 19.6% (p < 0.05). Improvements in Target-Stepping Task success rates depended on the specific testing condition (time × body support × step direction, χ2(1) = 3.884, p < 0.05). All participants appreciated the training. CONCLUSION: The concept of C-Mill gait adaptability training in the chronic phase after stroke is promising and warrants future research involving a randomized controlled trial.

Brain injury severity and autonomic dysregulation accurately predict heterotopic ossification in patients with traumatic brain injury.

OBJECTIVE: To assess brain injury severity, autonomic dysregulation and systemic infection as risk factors for the occurrence of heterotopic ossification in patients with severe traumatic brain injury. DESIGN: Historic cohort study. SETTING: Radboud University Medical Centre. SUBJECTS: All consecutively admitted patients with severe traumatic brain injury (admission Glasgow Coma Scale score 8 or less) during the years 2002-2003. MAIN MEASURES: The development of clinically relevant heterotopic ossification, defined as painful swelling of joints with redness and decreased range of motion, confirmed radiographically. RESULTS: Seventy-six (64%) of the 119 patients survived and were eligible for further follow-up. Nine patients (12%) developed 20 symptomatic heterotopic ossifications, in one or more joints. Patients with heterotopic ossification had sustained more severe brain injuries, compared to the group without heterotopic ossification. The mean coma duration in the heterotopic ossification group was 28.11 days (SD 20.20) versus 7.54 days (SD 7.47) in the patients without heterotopic ossification (P < 0.001). The occurrence of autonomic dysregulation (relative risk (RR) 59.55, 95% confidence interval (CI) 8.39-422.36), diffuse axonal injury (RR 20.68, 95% CI 4.92-86.91), spasticity (RR 16.96, 95% CI 3.96-72.57) and systemic infection (RR 13.12, 95% CI 3.01-57.17) were all associated with an increased risk of developing symptomatic heterotopic ossification. However, only autonomic dysregulation had a high positive (88.9%, 95% CI 51.7-99.7) and negative (98.5%, 95% CI 91.9-99.9) predictive value with regard to heterotopic ossification. CONCLUSIONS: The occurrence of autonomic dysregulation may predict the chance of developing heterotopic ossification in patients with severe head injury.