Remodeling the Brain: Plastic Structural Brain Changes Produced by Different Motor Therapies After Stroke Treadmill Exercise Activates Subcortical Neural Networks and Improves Walking After Stroke: A Randomized Controlled Trial Little therapy, little physical activity: rehabilitation within the first 14 days of organized stroke unit care. Repetitive Practice of a Single Joint Movement for Enhancing Elbow Function in Hemiparetic Patients Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care Repetitive locomotor training and physiotherapy improve walking and basic activities of daily living after stroke: a single-blind, randomized multicentre trial (DEutsche GAngtrainerStudie, DEGAS) Relationships between upper-limb functional limitation and self-reported disability 3 months after stroke. The stroke impact scale version 2.0. Evaluation of reliability, validity, and sensitivity to change. The Psychosocial Effects of Exercise and Relaxation Classes for Persons Surviving a Stroke Task-Specific Training With Trunk Restraint on Arm Recovery in Stroke: Randomized Control Trial Protocol for the Locomotor Experience Applied Post-stroke (LEAPS) trial: a randomized controlled trial Remedial therapy after stroke: a randomised controlled trial. Impairment–oriented training and adaptive motor cortex reorganisation after stroke: a fTMS study Effect of severity of arm impairment on response to additional physiotherapy early after stroke A preliminary study to examine the effects of aerobic and therapeutic (nonaerobic) exercise on cardiorespiratory fitness and coronary risk reduction in stroke survivors. Effectiveness of unilateral and symmetrical bilateral task training for arm during the subacute phase after stroke: a randomized controlled trial Association of activity limitations and lower-limb explosive extensor power in ambulatory people with stroke. Arm ability training for stroke and traumatic brain injury patients with mild arm paresis: a single-blind, randomized, controlled trial. Prospective, Blinded, Randomized Crossover Study of Gait Rehabilitation in Stroke Patients Using the Lokomat Gait Orthosis Step training with body weight support: effect of treadmill speed and practice paradigms on poststroke locomotor recovery. CONSORT 2010 statement: Updated guidelines for reporting parallel group randomised trials Home training with and without additional group training in physically frail old people living at home: effect on health-related quality of life and ambulation The effect of a task-oriented intervention on arm function in people with stroke: a randomized controlled trial Impairment-oriented training or Bobath therapy for severe arm paresis after stroke: a single-blind, multicentre randomized controlled trial Group exercise can improve participants' mobility in an outpatient rehabilitation setting: a randomized controlled trial Cardiorespiratory fitness and stroke mortality in men. Effects of Task-Specific Locomotor and Strength Training in Adults Who Were Ambulatory After Stroke: Results of the STEPS Randomized Clinical Trial
Background and Purpose — Studies on adult stroke patients have demonstrated functional changes in cortical excitability , metabolic rate , or blood flow after motor therapy , measures that can fluctuate rapidly over time . This study evaluated whether evidence could also be found for structural brain changes during an efficacious rehabilitation program . Methods — Chronic stroke patients were r and omly assigned to receive either constraint-induced movement therapy ( n=16 ) or a comparison therapy ( n=20 ) . Longitudinal voxel-based morphometry was performed on structural MRI scans obtained immediately before and after patients received therapy . Results — The group receiving constraint-induced movement therapy exhibited far greater improvement in use of the more affected arm in the life situation than the comparison therapy group . Structural brain changes paralleled these improvements in spontaneous use of the more impaired arm for activities of daily living . There were profuse increases in gray matter in sensory and motor areas both contralateral and ipsilateral to the affected arm that were bilaterally symmetrical , as well as bilaterally in the hippocampus . In contrast , the comparison therapy group failed to show gray matter increases . Importantly , the magnitude of the observed gray matter increases was significantly correlated with amount of improvement in real-world arm use . Conclusions — These findings suggest that a previously overlooked type of brain plasticity , structural remodeling of the human brain , is harnessed by constraint-induced movement therapy for a condition once thought to be refractory to treatment : motor deficit in chronic stroke patients Background and Purpose — Stroke often impairs gait thereby reducing mobility and fitness and promoting chronic disability . Gait is a complex sensorimotor function controlled by integrated cortical , subcortical , and spinal networks . The mechanisms of gait recovery after stroke are not well understood . This study examines the hypothesis that progressive task-repetitive treadmill exercise ( T-EX ) improves fitness and gait function in subjects with chronic hemiparetic stroke by inducing adaptations in the brain ( plasticity ) . Methods — A r and omized controlled trial determined the effects of 6-month T-EX  ( n=37 ) versus comparable duration stretching ( CON , n=34 ) on walking , aerobic fitness and in a subset ( n=15/17 ) on brain activation measured by functional MRI . Results — T-EX significantly improved treadmill-walking velocity by 51 % and cardiovascular fitness by 18 % ( 11 % and −3 % for CON , respectively ; P<0.05 ) . T-EX but not CON affected brain activation during paretic , but not during nonparetic limb movement , showing 72 % increased activation in posterior cerebellar lobe and 18 % in midbrain ( P<0.005 ) . Exercise-mediated improvements in walking velocity correlated with increased activation in cerebellum and midbrain . Conclusions — T-EX  improves walking , fitness and recruits cerebellum-midbrain circuits , likely reflecting neural network plasticity . This neural recruitment is associated with better walking . These findings demonstrate the effectiveness of T-EX rehabilitation in promoting gait recovery of stroke survivors with long-term mobility impairment and provide evidence of neuroplastic mechanisms that could lead to further refinements in these paradigms to improve functional outcomes OBJECTIVE To examine rehabilitation interventions and result ing physical activity patterns of patients managed in acute stroke units to help inform development of a r and omized controlled trial of very early rehabilitation . DESIGN An open observational study of patient activity and therapist report of patient interventions . A survey of stroke unit re sources . METHODS Patients less than 14 days post-stroke from 5 metropolitan stroke units were observed over 2 consecutive weekdays at 10-minute intervals between 08.00 h and 17.00 h. Physical activity , location and person(s ) present were ascertained at each observation . Therapists completed treatment records . Senior staff completed stroke unit surveys . RESULTS Patients after stroke ( n=58 ) were with therapists 5.2 % of the observed day . Few patients ( 17.1 % ) received  daily therapy  by more than one therapist . When patients received therapy , average session times were 24 minutes of physiotherapy , 23 minutes of occupational therapy and 33 minutes of speech pathology .  The more time that family members were present , the longer the treatment time . Four to 11 min of upper-limb therapy was provided . Muscle weakness and left hemiparesis were associated with less upper-limb activity . CONCLUSION These acute stroke care units were re source d according to recommended staff-patient ratios . Patients received little therapy and had low levels of physical activity The primary goal of this study was to assess whether repetitive practice of flexion-extension movements of the affected elbow in hemiparetic patients enhances performance and to compare the effects of this practice mode to the effects of the physical therapy variable exercise program which is routinely applied during sessions . Subjects were 27 poststroke hemiparetic patients , residents of a rehabilitation institute , divided into an experimental ( n= 15 ) and a control group ( n = 12 ) . The former were treated with 800 repeated elbow movements in a maximal predetermined amplitude of 80 ° , provided in 8 equal sessions every other day . The latter received 10 min . of conventional physical therapy for the paretic upper extremity at similar time intervals . Pre- and posttreatment assessment s included the bilateral measurements of kinematic variables and activation latencies of the biceps and triceps brachi muscles as well as motor and functional tests . For all criterion variables , the findings pointed to comparable improvement in both groups . It was concluded that repetitive elbow movements had no unique training effect on the kinematics of movement and on activation latencies of the primary muscles controlling elbow function in hemiparetic patients . Further , transfer of the effects of training to execution of movements towards and from the mouth was also comparable in both groups , pointing again to there being no particular advantage in using repetitive movements as a training mode for enhancement of elbow function in hemiparetic patients Background and Purpose — One way that stroke units may improve outcome is by reducing complications of immobility through early mobilization ; however , this intervention needs testing . The purpose of this study was to determine the physical activity patterns of stroke patients managed within acute stroke units as a first step in developing an early mobilization protocol . Methods — We recruited 64 patients within 14 days after stroke from 5 metropolitan stroke units and observed them for 2 consecutive days at 10-minute intervals between the hours of 8 am and 5 pm . At each observation , we ascertained physical activity , location , and other person(s ) present . Therapists recorded therapy details . Results — The 58 patients who completed the study had a mean age of 71.3 years . Stroke severity ranged from mild ( National Institutes of Health Stroke Scale score , 1 ) to severe ( score , 27 ) , and mean time after stroke at observation was 5.6 days ( range , 0 to 13 days ) . Only 9 patients were restricted to bed . During the therapeutic day , patients spent > 50 % resting in bed , 28 % sitting out of bed , and only 13 % engaged in activities with the potential to prevent complications and improve recovery of mobility . Patients were alone > 60 % of the time . Conclusions — This is the first multicenter study of physical activity early after stroke . We believe the next step is to conduct a r and omized controlled trial to evaluate the effect of increased levels of  physical activity  early after stroke compared with current st and ards of care Objective : To evaluate the effect of repetitive locomotor training on an electromechanical gait trainer plus physiotherapy in subacute stroke patients . Design : R and omized controlled trial . Setting : Four German neurological rehabilitation centres . Subjects : One hundred and fifty-five non-ambulatory patients ( first-time stroke < 60 days ) . Intervention : Group A received 20 min locomotor training and 25 min physiotherapy ; group B had 45 min physiotherapy every week day for four weeks . Main outcome measures : Primary variables were gait ability ( Functional Ambulation Category , 0 - 5 ) and the Barthel Index ( 0 - 100 ) , blindly assessed at study onset , end , and six months later for follow-up . Responders to the therapy had to become ambulatory ( Functional Ambulation Category 4 or 5 ) or reach a Barthel Index of ≥ 75 . Secondary variables were walking velocity , endurance , mobility and leg power . Results : The intention-to-treat analysis revealed that significantly greater number of patients in group A could walk independently : 41 of 77 versus 17 of 78 in group B ( P B < 0.0001 ) at treatment end . Also , significantly more group A patients had reached a Barthel Index ≥ 75 : 44 of 77 versus 21 of 78 ( P B < 0.0001 ) . At six-month follow-up , the superior gait ability in group A persisted ( 54 of 77 versus 28 of 78 , P B < 0.0001 ) , while the Barthel Index responder rate did not differ . For all secondary variables , group A patients had improved significantly more ( P B < 0.0001 ) during the treatment period , but not during follow-up . Conclusions : Intensive locomotor training plus physiotherapy result ed in a significantly better gait ability and daily living competence in subacute stroke patients  compared with physiotherapy alone This study explored relationships between upper-limb ( UL ) functional limitations and self-reported disability in stroke patients with relatively pure motor hemiparesis who were enrolled in an acute rehabilitation treatment trial . All participants were enrolled in the VECTORS ( Very Early Constraint Treatment for Recovery from Stroke ) study . VECTORS is a single-center pilot clinical trial of early application of constraint-induced movement therapy ( CIMT ) . All 39 subjects who completed 90 days of VECTORS  were included in this analysis . Trained study personnel who were blinded to the treatment type performed all evaluations . Data in this article examine relationships between assessment s performed 90 days after stroke . Functional limitation measures included the Action Research Arm ( ARA ) test and Wolf Motor Function Test ( WMFT ) , and self-reported disability measures included the Functional Independence Measure ( FIM ) and Motor Activity Log ( MAL ) ( by telephone ) . Mean plus or minus st and ard deviation time from stroke onset to r and omization was 9.4 plus or minus 4.3 days , and median time to follow-up was 99 days ( range 68 - 178 ) . Subjects with perfect or near-perfect scores on the ARA test or WMFT reported residual disability on the FIM and MAL . Quality of movement on the WMFT ( functional ability score ) was not strongly associated with self-reported frequency , and speed of movement on the WMFT ( timed score ) was not associated with self-reported frequency ( MAL amount of use ) . In this early UL intervention trial , we found that perceived disability measures captured information that was not assessed by functional limitation and impairment scales . Our results indicate that excellent motor recovery as measured by functional limitation and impairment scales did not equal restoration of everyday productive UL use and speed of task completion did not translate to actual use . Our results confirm the need for a measurement strategy that is sensitive to change , assesses a broad performance range , and detects meaningful clinical improvements in early rehabilitation intervention trials BACKGROUND AND PURPOSE To be useful for clinical research , an outcome measure must be feasible to administer and have sound psychometric attributes , including reliability , validity , and sensitivity to change . This study characterizes the psychometric properties of the Stroke Impact Scale ( SIS ) Version 2.0 . METHODS Version 2.0 of the SIS is a self-report measure that includes 64 items and assesses 8 domains ( strength , h and function , ADL/IADL , mobility , communication , emotion , memory and thinking , and participation ) . Subjects with mild and moderate strokes completed the SIS at 1 month ( n=91 ) , at 3 months ( n=80 ) , and at 6 months after stroke ( n=69 ) . Twenty-five subjects had a replicate administration of the SIS 1 week after the 3-month or 6-month test . We evaluated internal consistency and test-retest reliability . The validity of the SIS domains was examined by comparing the SIS to existing stroke measures and by comparing differences in SIS scores across Rankin scale levels . The mixed model procedure was used to evaluate responsiveness of the SIS domain scores to change . RESULTS Each of the 8 domains met or approached the st and ard of 0.9 alpha-coefficient for comparing the same patients across time . The intraclass correlation coefficients for test-retest reliability of SIS domains ranged from 0.70 to 0.92 , except for the emotion domain ( 0.57 ) . When the domains were compared with established outcome measures , the correlations were moderate to strong ( 0.44 to 0.84 ) . The participation domain was most strongly associated with SF-36 social role function . SIS domain scores discriminated across 4 Rankin levels . SIS domains are responsive to change due to ongoing recovery . Responsiveness to change is affected by stroke severity and time since stroke . CONCLUSIONS This new , stroke-specific outcome measure is reliable , valid , and sensitive to change . We are optimistic about the utility of measure . More studies are required to evaluate the SIS in larger and more heterogeneous population s and to evaluate the feasibility and validity of proxy responses for the most severely impaired patients Background . This study was set up to explore unexpected findings emergent from a r and omized controlled trial of exercise versus relaxation post-stroke . Purpose . Stroke survivors ' experiences of taking part in exercise and relaxation classes were explored . Methods . In-depth , semi-structured interviews carried out with 14 community-dwelling stroke survivors in Edinburgh . The informants previously participated in a r and omized exploratory trial of exercise versus relaxation . Findings . The classes motivated participants to take part in other purpose ful activities , to continue to practice what they had learned , and /or to attend another class in the community . Class participation also led to an improvement of self-perceived quality of life , specifically , improved confidence , physical ability , psychosocial functioning , and a sense of empowerment . Implication s. Taking part in either exercise or relaxation classes after stroke can contribute to improved self-perceived quality of life , improved psychosocial functioning , and improved motivation to take an active role in the recovery process Background and Purpose — Task-specific training improves functional outcomes after stroke . However , gains may be accompanied by increases in movements compensating for motor impairments . We hypothesized that restriction of compensatory trunk movements may encourage recovery of premorbid movement patterns leading to better functional outcomes . The goal was to determine whether task-specific training with trunk-restraint ( TR ) produces greater improvements in arm impairment and function than training without TR in patients with chronic hemiparesis . Methods — Double-blind r and omized control trial of a therapist-supervised home program ( 3 times per week , 5 weeks ) in 30 patients with chronic hemiparesis stratified by arm impairment level ( Fugl-Meyer ) was performed . Intervention group ( TR group ) received progressive object-related reach-to-grasp training with prevention of trunk movements . Control group ( C ) practice d tasks without TR . Main outcome measures were upper limb impairment ( Fugl-Meyer Arm Section ) and function ( TEMPA ) and movement kinematics ( trunk displacement , elbow extension ; Optotrak , 10 trials ) of a reach-to-grasp movement . Evaluations were repeated before , immediately after , and 1 month postintervention by blind evaluators . Results — TR training led to greater improvements in impairment and function compared with C. Improvements were accompanied by increased active joint range and were greater in initially more severe patients . In these patients , TR decreased trunk movement and increased elbow extension , whereas C had opposite effects ( increased compensatory movements ) . In TR , changes in arm function were correlated with changes in arm and trunk kinematics . Conclusions — Treatment should be tailored to arm impairment severity with particular attention to controlling excessive trunk movements if the goal is to improve arm movement quality and function Background Locomotor training using body weight support and a treadmill as a therapeutic modality for rehabilitation of walking post-stroke  is being rapidly adopted into clinical practice . There is an urgent need for a well- design ed trial to determine the effectiveness of this intervention . The objective of the Locomotor Experience Applied Post-Stroke ( LEAPS ) trial is to determine if there is a difference in the proportion of participants who recover walking ability at one year post-stroke when r and omized to a specialized locomotor training program ( LTP ) , conducted at 2- or 6-months post-stroke , or those r and omized to a home based non-specific , low intensity exercise intervention ( HEP ) provided 2 months post-stroke . We will determine if the timing of LTP delivery affects gait speed at 1 year and whether initial impairment severity interacts with the timing of LTP . The effect of number of treatment sessions will be determined by changes in gait speed taken pre-treatment and post-12 , -24 , and -36 sessions . Methods / Design We will recruit 400 adults with moderate or severe walking limitations within 30 days of stroke onset . At two months post stroke , participants are stratified by locomotor impairment severity as determined by overground walking speed and r and omly assigned to one of three groups : ( a ) LTP-Early ; ( b ) LTP-Late or ( c ) Home Exercise Program -Early . The LTP program includes body weight support on a treadmill and overground training . The LTP and HEP interventions are delivered for 36 sessions over 12 weeks . Primary outcome measure include successful walking recovery defined as the achievement of a 0.4 m/s gait speed or greater by persons with initial severe gait impairment or the achievement of a 0.8 m/s gait speed or greater by persons with initial moderate gait impairment . LEAPS is powered to detect a 20 % difference in the proportion of participants achieving successful locomotor recovery between the LTP groups and the HEP group , and a 0.1 m/s mean difference in gait speed change between the two LTP groups . Discussion The goal of this single-blinded , phase III r and omized clinical trial is to provide evidence to guide post-stroke walking recovery programs . Trial registration NCT00243919 Of 1094 patients with a confirmed stroke admitted to Northwick Park , a district general hospital , 364 ( 33 % ) died while in hospital , 215 ( 20 % ) were fully recovered when discharged , and 329 ( 30 % ) were too frail or too ill from diseases other than stroke to be considered for active rehabilitation . Only 121 ( 11 % ) were suitable for intensive treatment .  They and 12 patients referred direct to out patients were allocated at r and om to one of three different courses of rehabilitation . Intensive was compared with conventional rehabilitation and with a third regimen which included no routine rehabilitation , but under which patients were encouraged to continue with exercises taught while in hospital and were regularly seen at home by a health visitor .  Progress at three months and 12 months was measured by an index of activities of daily living . Improvement was greatest in those receiving intensive treatment , intermediate in those receiving conventional treatment , and least in those receiving no routine treatment .  Decreasing intensity of treatment was associated with a significant increase in the proportions of patients who deteriorated and in the extent to which they deteriorated . Probably only a few stroke patients , mostly men , are suitable for  intensive outpatient rehabilitation  , but for those patients the treatment is effective and realistic Abstract In a sample of 28 subacute anterior circulation ischemic stroke patients with severe arm paresis , reduced motor cortex excitability ( increased motor thresholds , reduced MEP amplitudes , reduced number of active points ) and a reduced conduction velocity in the corticospinal system were found in the affected hemisphere . At the same time motor cortex topology for the abductor pollicis brevis ( APB ) representation was comparable for the affected and non – affected hemisphere . Considerable arm motor recovery ( Fugl – Meyer test ) was observed when assessed four weeks later after a period of rehabilitation intervention . Motor cortex excitability and conduction velocity in the corticospinal system improved in the affected hemisphere . In addition , APB representation showed a medial shift in patients with such a representation at pre test ( n = 14 ) . Multiple stepwise regression indicated that of all transcranial magnetic stimulation ( TMS ) parameters only the medial shift of the motor cortex map predicted motor recovery . Assessing the effect of training time ( nonintensified vs. intensified therapy ) and type of arm training ( Bobath approach vs. Arm BASIS training ) with a r and omised controlled design revealed that the impairment – oriented Arm BASIS training improved motor control more than the control conditions . In addition , patients of the group receiving the Arm BASIS training with an APB representation at pre test showed a medial shift of the motor cortex map and improved conduction times . In conclusion , changes in motor cortex topology were likely to be relevant for motor recovery and might have been induced by the impairment – oriented training Objective : To investigate effect of initial severity of arm impairment on response to additional physiotherapy for the arm after stroke . Design : In this controlled trial , patients were r and omized into one of three groups :  routine physiotherapy ( RPT ) patients received no additional physiotherapy ; qualified physiotherapy ( QPT ) patients received additional treatment from a qualified physiotherapist ; assistant physiotherapy ( APT ) patients received additional treatment from a trained supervised assistant . Comparisons between the whole groups found no significant differences and have been reported elsewhere . In a post hoc analysis , the groups were subdivided according to severity of initial arm impairment . The subgroups were then compared . Setting : A general hospital with acute and rehabilitation facilities for stroke patients . Subjects : Patients ( n= 282 ) between one and five weeks after stroke . Interventions : Ten hours additional physiotherapy were given over a five-week period . The treatment approach reflected current usual British practice . ‘ Blind ’ outcome assessment was performed after intervention , and at three and six months after stroke . Main outcome measures : Rivermead Motor Assessment Arm Scale , Action Research Arm Test . Results : In more severe patients , no benefits of additional treatment were detected . In less severe patients , significant benefits were found in those who completed treatment with the trained assistant . However , a considerable number of patients did not complete the additional treatment . The content of treatment differed between the QPT and APT groups . Treatment of less severe APT patients emphasized repetitive supervised practice of movements and functional tasks . No significant effects of additional treatment were found in terms of shoulder pain or spasticity . Conclusions : Regardless of whether additional physiotherapy was given or not , patients with severe arm impairment improved very little in arm function . Enabling adaptation to loss of arm function may be an appropriate rehabilitation strategy for some patients . Trends in the data confirm findings of some previous studies that intensive treatment for patients with some motor recovery of the upper limb is effective . Following patient assessment and treatment planning by a qualified physiotherapist , it may be appropriate for guidance of repetitive practice of motor and functional tasks to be delegated to trained and closely supervised assistant staff OBJECTIVES To compare the effects of 3 different exercise training regimens on cardiorespiratory fitness and coronary risk factor reduction in subjects with unilateral stroke . DESIGN A cluster assignment by residential location repeated- measures design . SETTING University-based medical center . PARTICIPANTS Fifty-five subjects with unilateral ischemic stroke were assigned to the following groups : intensity ( n=18 ) , duration ( n=19 ) , and therapeutic exercise ( n=18 ) . INTERVENTION A 14-week intervention with subjects r and omized to 1 of 3 interventions : ( 1 ) moderate intensity , shorter duration ( MISD ) exercise ( gradually increasing exercise intensity while keeping exercise duration constant at 30 min ) , ( 2 ) low-intensity , longer duration ( LILD ) exercise ( gradually increasing duration to 60 min while keeping exercise intensity constant ) , or ( 3 ) conventional therapeutic exercise ( TE ) consisting mainly of strength , balance , and range of motion activities . All groups exercised 3 days per week . MAIN OUTCOME MEASURES Peak oxygen consumption ( VO2peak ) , submaximal oxygen consumption ( VO2 ) , lipid panel , and resting blood pressure . RESULTS The MISD group attained more favorable effects on systolic ( P<.04 ) and diastolic blood pressure ( P<.002 ) and total cholesterol ( TC ) ( P<.036 ) compared with LILD and TE groups . Both MISD ( P<.029 ) and LILD ( P<.045 ) showed significant reductions in triglycerides compared with TE ( P<.029 ) . There was no significant change in VO2peak and submaximal VO2 in any of the groups . CONCLUSIONS Overall , both MISD and LILD conditions achieved greater clinical and significant gains in coronary risk reduction compared with TE Objective : To evaluate the effect of an arm training programme combining repetition of unilateral and symmetrical bilateral tasks for people in the subacute phase after stroke . Design : R and omized controlled trial . Setting : Inpatient functional rehabilitation unit . Subjects : Forty-one people who had had a stroke , in the subacute phase , receiving conventional arm occupational and physical therapy  , were r and omized to an experimental group ( n=20 ) and a control group ( n=21 ) . Interventions : In addition to the usual arm therapy in the rehabilitation unit , the experimental group received an arm therapy programme ( 15 - 20 45-min sessions ) based on repetition of unilateral and symmetrical bilateral tasks . The control group received additional usual arm therapy of a similar duration and frequency to the experimental treatment . Main measures : The effect of the programme was judged on the basis of : ( 1 ) arm impairments ( motor function , grip strength , gross and fine manual dexterity and motor co-ordination ) , ( 2 ) arm disabilities in tasks related to daily activities , and ( 3 ) functional independence in activities of daily living ( ADL ) and instrumental ADL ( IADL ) . Results : Although both experimental and control groups of participants improved similarly during the study period , the statistical analyses did not show any difference between the groups at the end of the treatment for the different dependent variables evaluated : ( 1 ) arm impairments : p=0.43 - 0.79 ; ( 2 ) arm disabilities : p=0.16 - 0.90 ; and ( 3 ) functional independence : p=0.63 and 0.90 . Conclusions : An arm training programme based on repetition of unilateral and symmetrical bilateral practice did not reduce impairment and disabilities nor improve functional outcomes in the subacute phase after stroke more than the usual therapy OBJECTIVE To determine whether the explosive lower-limb extensor power of the affected and unaffected sides , and any asymmetry , are associated with activity limitations after stroke . DESIGN Cross-sectional observational study of baseline data from a r and omized controlled trial . SETTING Measurements made in a hospital clinical research facility . PARTICIPANTS Community-dwelling ( N=66 ) subjects with stroke who were independently ambulatory . Subjects ' mean age was 72+/-10 years . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES The  lower-limb extensor power of each lower limb ( in W/kg ) , performance of specific functional activities ( comfortable walking velocity , Functional Reach Test , chair-rise time , Timed Up & Go test ) , and global indices of activity limitation ( FIM instrument , Rivermead Mobility Index , Nottingham Extended Activities of Daily Living ) . RESULTS Low lower-limb extensor power in either lower limb was the principal factor from among the confounders we recorded that significantly ( R(2 ) range , .21-.46 ) predicted the limitation of specific functional activities , and low lower-limb extensor power in either lower limb was the principal predictive factor for global indices of activity limitation ( R(2 ) range , .13-.38 ) . The degree of asymmetry of lower-limb extensor power between legs was low and had little or no predictive value . CONCLUSIONS In ambulatory persons with stroke , activity limitations are associated with deficits in lower-limb extensor power of both lower limbs , and not the severity of any residual asymmetry . These findings suggest that interventions to increase lower-limb extensor power in both lower limbs might reduce activity limitations after stroke OBJECTIVE To test the efficacy of the arm ability training ( AAT ) on a sample of patients with central arm paresis after traumatic brain injury ( TBI ) or stroke . DESIGN Single-blind , r and omized , controlled trial . SETTING Inpatient rehabilitation center . PATIENTS Consecutive sample of 74 patients of whom 60 ( 45 with stroke , 15 with TBI ) completed the study ; 37 patients received a 1-year follow-up . INTERVENTION Daily AAT with ( n = 20 ) or without ( n = 20 ) knowledge of results , or no AAT ( n = 20 ) during a 3-week intervention period . MAIN OUTCOME MEASURES Summary time scores of the Test Evaluant les Membres superieurs des Personnes Agees (TEMPA)-a test of upper extremity function with daily function-like activities ( focal disability)- and kinematic analysis of aim ed movements . RESULTS Patients with AAT realized superior improvement as compared with controls . Mean improvement in the time needed to perform ( 1 ) all TEMPA tasks was 41.4 versus 12.8 seconds ( p = .0012 ) ; ( 2 ) unilateral TEMPA tasks , 16.5 versus 4.2 seconds ( p = .0036 ) ; and ( 3 ) the ballistic component of aim ed movements , 96 versus 20ms ( p = .0115 ) . Knowledge of result did not substantially modify these effects . A functional benefit existed at 1-year follow-up . CONCLUSION The AAT reduces focal disability among stroke and TBI patients with mild central arm paresis Objective . Treadmill training with partial body weight support has been suggested as a useful strategy for gait rehabilitation after stroke . This prospect i ve , blinded , r and omized controlled study of gait retraining tested the feasibility and potential efficacy of using an electromechanical-driven gait orthosis ( Lokomat ) for treadmill training . Methods . Sixteen stroke patients , mostly within 3 months after onset , were r and omized into 2 treatment groups , ABA or BAB ( A = 3 weeks of Lokomat training , B = 3 weeks of conventional physical therapy ) for 9 weeks of treatment . The outcome measures were the EU-Walking Scale , Rivermead Motor Assessment Scale , 10-m timed walking speed , 6-minute timed walking distance , Motricity Index , Medical Research Council Scale of strength , and Ashworth Scale of tone . Results . The EU-Walking Scale , Rivermead Motor Assessment Scale , 6-minute timed walking distance , Medical Research Council Scale , and Ashworth Scale demonstrated significantly more improvement during the Lokomat training phase than during the conventional physical therapy phase within each 3-week interval . Conclusions . Despite the small number of patients , the present data suggest that the Lokomat robotic assistive device provides innovative possibilities for gait training in stroke rehabilitation while eliminating prolonged repetitive movements in a nonergonomic position on the part of the physical therapist OBJECTIVE To investigate the effect of practice paradigms that varied treadmill speed during step training with body weight support in subjects with chronic hemiparesis after stroke . DESIGN R and omized , repeated- measures pilot study with 1- and 3-month follow-ups . SETTING Outpatient locomotor laboratory . PARTICIPANTS Twenty-four individuals with hemiparetic gait deficits whose walking speeds were at least 50 % below normal . INTERVENTION Participants were stratified by locomotor severity based on initial walking velocity and r and omly assigned to treadmill training at slow ( 0.5 mph ) , fast ( 2.0 mph ) , or variable ( 0.5 , 1.0 , 1.5 , 2.0 mph ) speeds . Participants received 20 minutes of training per session for 12 sessions over 4 weeks . MAIN OUTCOME MEASURE Self-selected overground walking velocity ( SSV ) was assessed at the onset , middle , and end of training , and 1 and 3 months later . RESULTS SSV improved in all groups compared with baseline ( P<.001 ) . All groups increased SSV in the 1-month follow-up ( P<.01 ) and maintained these gains at the 3-month follow-up ( P=.77 ) . The greatest improvement in SSV across training occurred with fast training speeds compared with the slow and variable groups combined ( P=.04 ) . Effect size ( ES ) was large between fast compared with slow ( ES=.75 ) and variable groups ( ES=.73 ) . CONCLUSIONS Training at speeds comparable with normal walking velocity was more effective in improving SSV than training at speeds at or below the patient 's typical overground walking velocity The CONSORT statement is used worldwide to improve the reporting of r and omised controlled trials . Kenneth Schulz and colleagues describe the latest version , CONSORT 2010 , which up date s the reporting guideline based on new method ological evidence and accumulating experience . To encourage dissemination of the CONSORT 2010 Statement , this article is freely accessible on bmj.com and will also be published in the Lancet , Obstetrics and Gynecology , PLoS Medicine , Annals of Internal Medicine , Open Medicine , Journal of Clinical Epidemiology , BMC Medicine , and Trials Objective : To test the effect of two exercise regimes on health-related quality of life ( HRQoL ) and ambulatory capacity . Design : R and omized controlled trial . Subjects : Seventy-seven community-dwelling physically frail people over 75 years of age ( mean=81 , SD=4.5 ) . Interventions : Home training ( HT , N = 38 ) comprised twice daily functional balance and strength exercises and three group meetings . Combined training ( CT , N = 39 ) included group training twice weekly and the same home exercises . Interventions lasted 12 weeks . Physiotherapists ran both programmes . Home exercises were recorded daily . Main measures : HRQoL was assessed by SF-36 , and ambulatory capacity by walking speed and frequency and duration of outdoor walks . Results : Following intervention , CT improved the SF-36 mental health index significantly more than HT ( p = 0.01 ) . The SF-36 physical health index ( p = 0.002 ) and walking speed ( p = 0.02 ) demonstrated improvements , but no group differences . Six months after cessation of intervention there was still overall improvements on the mental health index ( p = 0.032 ) , borderline overall improvements on the physical health index ( p = 0.057 ) , higher weekly number of outdoor walks for the CT group than for the HT group ( p = 0.027 ) and an improved habitual walking speed in the CT group only ( p = 0.022 ) . Conclusions : HT improved HRQoL and walking speed , but additional group training gave larger benefits on mental health . Group training away from home may be beneficial for mental health and ambulatory capacity Objective : To evaluate the efficacy of a task-oriented intervention in enhancing arm function in people with stroke . Design : Two-centre , observer-blinded , stratified , block-r and omized controlled trial . Setting : General community . Patients : Ninety-one individuals within one year of a first or recurrent stroke consented to participate between May 2000 and February 2003 . Interventions : The experimental intervention involved practice of functional , unilateral and bilateral tasks that were design ed to improve gross and fine manual dexterity whereas the control intervention was composed of walking tasks . Members in both groups participated in three sessions a week for six weeks . Main outcome measure(s ) : The primary test of arm function was the Box and Block Test . Secondary tests included the Nine-Hole Peg Test , maximal grip strength , the Test d'Evaluation des Membres supé rieurs des Personnes Agées ( TEMPA ) and the Stroke Rehabilitation Assessment of Movement . Results : Results are for the more affected arm . Baseline performance on the Box and Block Test was an average of 26 blocks ( st and ard deviation ( SD=16 ) in the experimental group ( n=47 ) and 26 blocks ( Sd=18 ) in the control group ( n=44 ) . These values represent approximately 40 % of age-predicted values . Values for the postintervention evaluation were an average of 28 ( SD=17 ) and 28 ( SD=19 ) blocks for the experimental and control group respectively . No meaningful change on other measures of arm function was observed . Conclusions : A task-oriented intervention did not improve voluntary movement or manual dexterity of the affected arm in people with chronic stroke Objective : To study the effects of augmented exercise therapy time for arm rehabilitation as either Bobath therapy or the impairment-oriented training ( Arm BASIS training ) in stroke patients with arm severe paresis . Design : Single blind , multicentre r and omized control trial . Setting : Three inpatient neurorehabilitation centres . Subjects : Sixty-two anterior circulation ischaemic stroke patients . Interventions : R and om assignment to three group : ( A ) no augmented exercise therapy time , ( B ) augmented exercise therapy time as Bobath therapy and ( C ) augmented exercise therapy time as Arm BASIS training . Main measures : Main outcome measure : Fugl-Meyer arm motor score . Secondary measure : Action Research Arm Test ( ARA ) . Ancillary measures : Fugl-Meyer arm sensation and joint motion/pain scores and the Ashworth Scale ( elbow flexors ) . Results : An overall effect of  augmented exercise therapy  time on Fugl-Meyer scores after four weeks was not corroborated ( mean and 95 % confidence interval ( CI ) of change scores : no augmented exercise therapy time ( n = 20 ) 8.8 , 5.2–12.3 ; augmented exercise therapy time ( n = 40 ) 9.9 , 6.8 - 13.9 ; p = 0.2657 ) . The group who received the augmented exercise therapy time as Arm BASIS training ( n = 20 ) had , however , higher gains than the group receiving the  augmented exercise therapy time as Bobath therapy  ( n = 20 ) ( mean and 95 % CI of change scores : Bobath 7.2 , 2.6 - 11.8 ; BASIS 12.6 , 8.4 - 16.8 ; p = 0.0432 ) . Passive joint motion/pain deteriorated less in the group who received BASIS training ( mean and 95 % CI of change scores : Bobath -3.2 , -5.2 to -1.1 ; BASIS 0.1 , -1.8 - 2.0 ; p = 0.0090 ) . ARA , Fugl-Meyer arm sensation , and Ashworth Scale scores were not differentially affected . Conclusions : The augmented exercise therapy time as Arm BASIS training enhanced selective motor control . Type of training was more relevant for recovery of motor control than therapeutic time spent Objective : To establish the effects of group exercise on mobility and strength . Design : R and omized controlled trial . Setting : Two public hospital outpatient rehabilitation services . Participants : One hundred and seventy-three people ( mean age 74.9 years , SD 10.8 ) with impaired mobility were r and omized and 159 people ( 92 % ) completed the trial . Interventions : Five-week , twice-weekly ` circuit-style ' group exercise programme run by a physiotherapist ( n = 85 ) and a no-intervention waiting list control group ( n = 88 ) . Main outcome measures : Three aspects of mobility : balance while st and ing and stepping ( Step Test , semi-t and em and t and em stance times ) ; sit-to-st and ability ( rate and minimum height ) and gait ( 6-metre and 6-minute walk tests ) . Lower limb muscle strength ( knee flexion and extension ) . Results : At retest , exercise participants had improved significantly more than their control counterparts on measures of balance while stepping , sit to st and and gait . Exercise participants averaged 1.6 more steps on the 15-second Step Test ( 95 % confidence interval ( CI ) 0.5 to 2.8 , P=0.005 ) , walked an average of 0.12 m/s faster ( 95 % CI 0.05 to 0.2 , P=0.002 ) and took 2.5 fewer steps in 6 metres ( 95 % CI —4.2 to —0.8 , P=0.004 ) . Exercise participants also averaged 0.04 more sit-to-st and s/second , ( 95 % CI 0.003 to 0.08 , P=0.037 ) and walked an average of 30.9 metres further in 6 minutes ( 95 % CI 9.4 to 52.4 , P=0.005 ) . There were no clinical ly important or statistically significant between-group differences at retest for the measures of strength ( knee extension and flexion ) , balance while st and ing or minimal sit-to-st and height . Conclusion : This short- duration circuit class programme improved mobility , but not strength PURPOSE We examined the association between cardiorespiratory fitness and stroke mortality in men . METHODS This is a prospect i ve cohort study . We followed 16,878 men , ages 40 - 87 yr , who had a complete medical evaluation including a maximal treadmill exercise test and self-reported health habits .  There were 32 stroke deaths  during an average of 10 yr of follow-up ( 167,961 man-yr ) . RESULTS After adjustment for age and examination year , there was an inverse association between cardiorespiratory fitness and stroke mortality ( P = 0.005 for trend ) . This association remained after further adjustment for cigarette smoking , alcohol intake , body mass index , hypertension , diabetes mellitus , and parental history of coronary heart disease ( P = 0.02 for trend ) . High-fit men ( most fit 40 % ) had 68 % ( 95 % CI : 0.12 , 0.82 ) and moderate-fit men had 63 % ( 95 % CI : 0.17 , 0.83 ) lower risk of stroke mortality when compared with low-fit men ( least fit 20 % ) , respectively . CONCLUSIONS Moderate and high levels of cardiorespiratory fitness were associated with lower risk of stroke mortality in men in the Aerobics Center Longitudinal study population Background and Purpose : A phase II , single-blinded , r and omized clinical trial was conducted to determine the effects of combined task-specific and lower-extremity ( LE ) strength training to improve walking ability after stroke . Subjects : The participants were 80 adults who were ambulatory 4 months to 5 years after a unilateral stroke . Method : The exercise interventions consisted of body-weight – supported treadmill training ( BWSTT ) , limb-loaded resistive leg cycling ( CYCLE ) , LE muscle-specific progressive-resistive exercise ( LE-EX ) , and upper-extremity ergometry ( UE-EX ) . After baseline assessment s , participants were r and omly assigned to a combined exercise program that included an exercise pair . The exercise pairs were : BWSTT/UE-EX , CYCLE/UE-EX , BWSTT/CYCLE , and BWSTT/LE-EX . Exercise sessions were 4 times per week for 6 weeks ( total of 24 sessions ) , with exercise type completed on alternate days . Outcomes were self-selected walking speed , fast walking speed , and 6-minute walk distance measured before and after intervention and at a 6-month follow-up . Results : The BWSTT/UE-EX group had significantly greater walking speed increases compared with the CYCLE/UE-EX group ; both groups improved in distance walked . All BWSTT groups increased walking speed and distance whether BWSTT was combined with LE strength training or not . Discussion and Conclusion : After chronic stroke , task-specific training during treadmill walking with body-weight support is more effective in improving walking speed and maintaining these gains at 6 months than resisted leg cycling alone . Consistent with the overtraining literature , LE strength training alternated daily with BWSTT walking did not provide an added benefit to walking outcomes
BACKGROUND Levels of physical fitness are low after stroke .
It is unknown whether improving physical fitness after stroke reduces disability .
OBJECTIVES To determine whether fitness training after stroke reduces death , dependence , and disability .
The secondary aims were to determine the effects of training on physical fitness , mobility , physical function , quality of life , mood , and incidence of adverse events .