Long term effects of intensity of upper and lower limb training after stroke: a randomised trial Effect of a therapeutic intervention for the hemiplegic upper limb in the acute phase after stroke: a single-blind, randomized, controlled multicenter trial. A study on additional early physiotherapy after stroke and factors affecting functional recovery Randomized clinical trial of therapeutic exercise in subacute stroke. Physiotherapy for patients with mobility problems more than 1 year after stroke: a randomised controlled trial Are stroke patients discharged sooner if in-patient rehabilitation services are provided seven v six days per week? Is dosage of physiotherapy a critical factor in deciding patterns of recovery from stroke: a pragmatic randomized controlled trial. Does an early increased-intensity interdisciplinary upper limb therapy programme following acute stroke improve outcome? Effectiveness of an intensive outpatient rehabilitation program for postacute stroke patients. Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. The significance of intensity of rehabilitation of stroke--a controlled trial. Group physiotherapy improves time use by patients with stroke in rehabilitation. Unpacking the black box of therapy – a pilot study to describe occupational therapy and physiotherapy interventions for people with stroke Enhanced physical therapy for arm function after stroke: a one year follow up study. Enhanced physical therapy improves recovery of arm function after stroke. A randomised controlled trial. Randomized, controlled trial to evaluate increased intensity of physiotherapy treatment of arm function after stroke. Domiciliary occupational therapy for patients with stroke discharged from hospital: randomised controlled trial Remedial therapy after stroke: a randomised controlled trial. Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Effect of severity of arm impairment on response to additional physiotherapy early after stroke Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomised trial A randomised controlled trial to determine the effect of intensity of therapy upon length of stay in a neurological rehabilitation setting. The effects of increased rehabilitation therapy after brain injury: results of a prospective controlled trial A multicentre randomized controlled trial of leisure therapy and conventional occupational therapy after stroke A randomized controlled trial of enhanced Social Service occupational therapy for stroke patients Occupational therapy for stroke patients not admitted to hospital: a randomised controlled trial Physiotherapy intervention late after stroke and mobility. Can augmented physiotherapy input enhance recovery of mobility after stroke? A randomized controlled trial Task-specific physical therapy for optimization of gait recovery in acute stroke patients. Effect of duration of upper- and lower-extremity rehabilitation sessions and walking speed on recovery of interlimb coordination in hemiplegic gait.
Objective : To assess long term effects at 1 year after stroke in patients who participated in an upper and lower limb intensity training programme in the acute and subacute rehabilitation phases . Design : A three group r and omised controlled trial with repeated measures was used . Method : One hundred and one patients with a primary middle cerebral artery stroke were r and omly allocated to one of three groups for a 20 week rehabilitation programme with an emphasis on ( 1 ) upper limb function , ( 2 ) lower limb function or ( 3 ) immobilisation with an inflatable pressure splint ( control group ) . Follow up assessment s within and between groups were compared at 6 , 9 , and 12 months after stroke . Results : No statistically significant effects were found for treatment assignment from 6 months onwards . At a group level , the significant differences in efficacy demonstrated at 20 weeks after stroke in favour of the lower limb remained . However , no significant differences in functional recovery between groups were found for Barthel index ( BI ) , functional ambulation categories (FAC),action research arm test ( ARAT ) , comfortable and maximal walking speed , Nottingham health profile part 1(NHP-part 1 ) , sickness impact profile-68 ( SIP-68 ) , and Frenchay activities index ( FAI ) from 6 months onwards . At an individual subject level a substantial number of patients showed improvement or deterioration in upper limb function ( n=8 and 5 , respectively ) and lower limb function ( n=19 and 9 , respectively ) . Activities of daily living ( ADL ) scores showed that five patients deteriorated and four improved beyond the error threshold from 6 months onwards . In particular , patients with some but incomplete functional recovery at 6 months are likely to continue to improve or regress from 6 months onwards . Conclusions : On average patients maintained their functional gains for up to 1 year after stroke after receiving a 20 week upper or lower limb function training programme . However , a significant number of patients with incomplete recovery showed improvements or deterioration in dexterity , walking ability , and ADL beyond the error threshold BACKGROUND AND PURPOSE Arm function recovery is notoriously poor in stroke patients . The effect of treatment modalities , particularly those directed at improving upper limb function , has been studied primarily in chronic stroke patients . The purpose of this study was to investigate the effect of a specific therapeutic intervention on arm function in the acute phase after stroke . METHODS In a single-blind , r and omized , controlled multicenter trial , 100 consecutive patients were allocated to either an experimental group that received an additional treatment of sensorimotor stimulation or to a control group . The intervention was applied for 6 weeks . Patients were evaluated for level of impairment ( Brunnström-Fugl-Meyer test ) and disability ( Action Research Arm test , Barthel Index ) before , midway , and after the intervention period and at follow-up 6 and 12 months after stroke . RESULTS Patients in the experimental group performed better on the Brunnström-Fugl-Meyer test than those in the control group throughout the study period , but differences were significant only at follow-up . Results on the Action Research Arm test and Barthel Index revealed no effect at the level of disability . The effect of the therapy was attributed to the repetitive stimulation of muscle activity . The treatment was most effective in patients with a severe motor deficit and hemianopia or hemi-inattention . No adverse effects due to the intervention were found . CONCLUSIONS Adding a specific intervention during the acute phase after stroke improved motor recovery , which was apparent 1 year later . These results emphasize the potential beneficial effect of therapeutic interventions for the arm Objective : To investigate whether additional early physiotherapy after stroke improved functional recovery in stroke patients . Design : A prospect i ve , r and omized , controlled study . Setting : One stroke ward and an acute stroke unit in a large teaching hospital , southern China . Subjects : Patients with first-onset stroke consecutively admitted to the stroke centre . Interventions : One group ( n = 78 ) received additional early physiotherapy ( AEP ) for 45 minutes , five days a week for four weeks starting within the first week since stroke onset ; the routine therapy ( RT ) group ( n = 78 ) received no professional rehabilitation therapy . Main outcome measures : Glasgow Coma Scale , Mini-Mental State Examination , Fugl-Meyer Assessment of Motor Recovery , Clinical Neurological Deficit Scale and Modified Barthel Index ( MBI ) . Results : Patients from the AEP group had a high drop-out rate ( n = 28 ) , but those remaining made relatively better functional recovery at 30 days than those from the RT group if measured by MBI . Multiple linear regression analysis revealed that cognitive disturbance , aphasia , double incontinence , site of lesion and sensory impairment might affect functional recovery after stroke . Conclusions : Additional early physiotherapy might improve independence of patients after stroke but failed to show benefit in other aspects in our study . Cognitive disturbance , aphasia , double incontinence , site of lesion as well as sensory impairment might affect functional outcome after stroke BACKGROUND AND PURPOSE Rehabilitation care after stroke is highly variable and increasingly shorter in duration . The effect of therapeutic exercise on impairments and functional limitations after stroke is not clear . The objective of this study was to determine whether a structured , progressive , physiologically based exercise program for subacute stroke produces gains greater than those attributable to spontaneous recovery and usual care . METHODS This r and omized , controlled , single-blind clinical trial was conducted in a metropolitan area and 17 participating healthcare institutions . We included persons with stroke who were living in the community . One hundred patients ( mean age , 70 years ; mean Orpington score , 3.4 ) consented and were r and omized from a screened sample of 582 . Ninety-two subjects completed the trial . Intervention was a structured , progressive , physiologically based , therapist-supervised , in-home program of thirty-six 90-minute sessions over 12 weeks targeting flexibility , strength , balance , endurance , and upper-extremity function . Main outcome measures were postintervention strength ( ankle and knee isometric peak torque , grip strength ) , upper- and lower-extremity motor control ( Fugl Meyer ) , balance ( Berg and functional reach ) , endurance ( peak aerobic capacity and exercise duration ) , upper-extremity function ( Wolf Motor Function Test ) , and mobility ( timed 10-m walk and 6-minute walk distance ) . RESULTS In the intention-to-treat multivariate analysis of variance testing the overall effect , the intervention produced greater gains than usual care ( Wilk 's lambda=0.64 , P=0.0056 ) . Both intervention and usual care groups improved in strength , balance , upper- and lower-extremity motor control , upper-extremity function , and gait velocity . Gains for the intervention group exceeded those in the usual care group in balance , endurance , peak aerobic capacity , and mobility . Upper-extremity gains exceeded those in the usual care group only in patients with higher baseline function . CONCLUSIONS This structured , progressive program of therapeutic exercise in persons who had completed acute rehabilitation services produced gains in endurance , balance , and mobility beyond those attributable to spontaneous recovery and usual care BACKGROUND Community physiotherapy is often prescribed for stroke patients with long-term mobility problems . We aim ed to assess the effectiveness of this treatment in patients who had mobility problems 1 year after stroke . METHODS We screened 359 patients older than 50 years for a single-masked , r and omised controlled trial to assess the effects of community physiotherapy . Assessment s were made at baseline , 3 , 6 , and 9 months in 170 eligible patients assigned treatment or no intervention . The primary outcome measure was mobility measured by the Rivermead mobility index . Secondary outcome measures were gait speed , number of falls , daily activity ( Barthel index scores ) , social activity ( Frenchay activities index ) , hospital anxiety and depression scale , and emotional stress of carers ( general health question naire 28 ) . Analyses were by intention to treat . FINDINGS Follow-up was available for 146 patients ( 86 % ) . Changes in scores on the Rivermead mobility index ( score range 0 - 15 ) differed significantly between treatment and control groups at 3 months ( p=0.018 ) , but only by a median of 1 point ( 95 % CI 0 - 1 ) , with an interpolated value of 0.55 ( 0.08 - 1.04 ) . Gait speed was 2.6 m/min ( 0.30 - 4.95 ) higher in the treatment group at 3 months . Neither treatment effect persisted at 6-months ' and 9-months ' follow-up . Treatment had no effect on patients ' daily activity , social activity , anxiety , depression , and number of falls , or on emotional stress of carers . INTERPRETATION Community physiotherapy treatment for patients with mobility problems 1 year after stroke leads to significant , but clinical ly small , improvements in mobility and gait speed that are not sustained after treatment ends A comparison was made of 113 consecutive patients who suffered a cerebrovascular accident and were hospitalized at a rehabilitation inpatient unit by dividing them into two groups : one group received the traditional 6-day/wk treatment regimen , and another group received treatment during the entire week ( 7 days/wk ) . When the patients were asked whether they had a preference ( which did not affect their group assignment ) , 82 % preferred a 6-day/wk program and 18 % preferred a 7-day/wk program . The length of inpatient stay for the 57 patients enrolled in the 6-day/wk program was 20.14 days ; for the 56 patients enrolled in the 7-day/wk program , the average length of stay was 20.11 days . This represents no significant difference . The functional recoveries were evaluated in areas that can affect length of stay , including dressing , bladder control , ambulation , and problem-solving . Both groups demonstrated significant gains in each domain when the intake and discharge ratings were compared . However , these gains were not significantly different when the 6- and 7-day/wk groups were compared . The results of the study contained herein , therefore , suggest that a 6-day/wk program for patients who have suffered a cardiovascular accident is just as effective as a 7-day/wk program BACKGROUND AND PURPOSE The best treatment and management of stroke patients has been shown to be in stroke units by multidisciplinary rehabilitation teams . Since the composition of stroke units differs it is important to know the extent to which the different components contribute to this results . Physiotherapy is one component of most rehabilitation teams and recent systematic review s have shown that patients with stroke receiving more physiotherapy  achieve more recovery from disability . However , information about the actual amounts of physiotherapy needed to achieve this result is not known . METHOD A pragmatic , r and omized , single-blind , controlled trial comparing recovery from disability in subjects receiving the current st and ard amount of 30 minutes ' physiotherapy with those receiving double that amount ( 60 minutes ) . The study included measures of physical performance and function , psychological aspects of anxiety and depression , and perceived control over recovery . RESULTS Some 114 subjects were recruited to the study ; full six-week data are available for 104 subjects and six-month data for 93 subjects . Comparison of initial to six-week difference scores in the control and intervention groups of the whole sample did not show a significant difference . Scrutiny of the recovery curves of the whole sample showed that , in half the sample , three distinct patterns of recovery were demonstrated . CONCLUSION These results suggest that doubling the physiotherapy time available for patients in a stroke unit will not provide a measurable benefit for all patients . The subgroup analysis of patterns of recovery must be regarded as speculative , but provides the basis for hypotheses about those likely to respond well to more intensive therapy Objective : To determine whether an early increased-intensity upper limb therapy programme following acute stroke improves outcome . Design : A r and omized controlled trial . Setting : A stroke unit which provides acute care and rehabilitation for all stroke admissions . Subjects : One hundred and twenty-three patients who had had a stroke causing upper limb impairment within the previous 10 days . Intervention : The intervention group received stroke unit care plus enhanced upper limb rehabilitation provided jointly by a physiotherapist and occupational therapist , commencing within 10 days of stroke , and available up to 30 minutes/day , five days/week for six weeks . The control group received stroke unit care . Main outcome measures : The primary outcome measure was the Action Research Arm Test ( ARAT ) three months after stroke . Secondary outcome measures : Motricity Index ; Frenchay Arm Test ; upper limb pain ; Barthel ADL Index ; Nottingham E-ADL Scale ; and costs to health and social services at three and six months after stroke . Results : There were no differences in outcomes between the intervention and control groups three and six months after stroke . During the intervention period the intervention group received a median of 29 minutes of enhanced upper limb therapy per working day as in patients . The total amount of inpatient physiotherapy and occupational therapy received by the intervention group was a median of 52 minutes per working day during the intervention period and 38 minutes per working day for the control group ( p = 0.001 ) . There were no differences in service costs . Conclusions : An early increased-intensity interdisciplinary upper limb therapy programme jointly provided by a physiotherapist and occupational therapist did not improve outcome after stroke . The actual difference in the amount of therapy received by intervention and control groups was less than planned due to a competitive therapy bias The effectiveness of ongoing rehabilitation services for postacute stroke survivors is poorly documented . We design ed a r and omized control , single-blinded study to demonstrate the effectiveness of intensive outpatient therapy . The treatment intervention consisted of 1 hr each of physical and occupational therapy , four times per week , for 12 wk ; therapy focused on neuromuscular facilitation and functional tasks . All subjects were screened before the therapies and after 3 mo and 9 mo . Forty-nine stroke survivors , who were at least l yr ( mean , 2.9 yr ) poststroke , were r and omized with two treated patients to each control ( no treatment supplied ) . All patients had received inpatient rehabilitation at the time of their acute stroke , but no patient had any ongoing therapy  within the last 6 mo . The outcome measures included the Functional Independence Measure ( FIM ) , Brunnstrom stages of motor recovery , timed mobility tasks , and the Jebson h and evaluation . We also evaluated the level of depression , self-esteem , and socialization . The treated patients demonstrated an improvement of 6.6 points over the 3 mo of therapy compared with only 1.5 points in the control group in the FIM motor score transformed using Rasch analysis . The change from time 0 to 3 mo was significant in the treated group but not in the controls . Treated patients maintained their gains at the 9-mo follow-up , and controls lost ground . The treated group improved in terms of socialization and self-esteem as evidence d by a lower Sickness Impact Profile , whereas the controls tended to get worse . There was a trend toward less depression , but this did not reach a P = 0.05 level of significance . This study demonstrates that significant functional gains can still be attained in the postacute stroke survivor , despite prior inpatient rehabilitation services BACKGROUND AND PURPOSE To improve the accuracy of early postonset prediction of motor recovery in the flaccid hemiplegic arm , the effects of change in motor function over time on the accuracy of prediction were evaluated , and a prediction model for the probability of regaining dexterity at 6 months was developed . METHODS In 102 stroke patients , dexterity and paresis were measured with the  Action Research Arm Test , Motricity Index , and Fugl-Meyer motor evaluation .  For model development , 23 c and i date determinants were selected . Logistic regression analysis was used for prognostic factors and model development . RESULTS At 6 months , some dexterity in the paretic arm was found in 38 % , and complete functional recovery was seen in 11.6 % of the patients . Total anterior circulation infa rcts , right hemisphere strokes , homonymous hemianopia , visual gaze deficit , visual inattention , and paresis were statistically significant related to a poor arm function . Motricity Index leg scores of at least 25 points in the first week and Fugl-Meyer arm scores of 11 points in the second week increasing to 19 points in the fourth week raised the probability of developing some dexterity ( Action Research Arm Test > or=10 points ) from 74 % ( positive predictive value [ PPV ] , 0.74 ; 95 % confidence interval [ CI ] , 0.63 to 0.86 ) to 94 % ( PPV , 0.83 ; 95 % CI , 0.76 to 0.91 ) at 6 months . No change in probabilities of prediction dexterity was found after 4 weeks . CONCLUSIONS Based on the Fugl-Meyer scores of the flaccid arm , optimal prediction of arm function outcome at 6 months can be made within 4 weeks after onset . Lack of voluntary motor control of the leg in the first week with no emergence of arm synergies at 4 weeks is associated with poor outcome at 6 months Of the 373 stroke patients 95 were admitted to the feasibility study of stroke rehabilitation . The patients were divided into two groups , an intensive and a normal treatment group . In this study , the functional recovery of stroke , measured by ADL and motor function was significantly better in the intensive treatment group . There was no difference in institutionalization or incidence of death between the groups . The gain of ADL and motor function was greatest during the first three months after stroke in the intensive treatment group . The conclusion is that intensified physiotherapy seems to improve the functional recovery of stroke patients Does feedback about the  time use of patients with stroke influence the organisation of services in rehabilitation ? An observation was made of the time use by 22 patients with stroke in a specialised rehabilitation unit , feedback was given to the staff , and another observation on 16 patients was made one year later . As a result of the first observation , the physiotherapy staff were urged to organise group sessions for patients with similar levels of disability , allowing practice with a higher patient to staff ratio . During the second observation , patients spent significantly more time on therapy ( 8 % ) and with their peers ( 25 % ) . These results indicate that  feedback about patients ' time use  can substantially influence management and consequently patients ' behaviour in rehabilitation Objective : To describe the components used in the practice of occupational therapy and physiotherapy for people with stroke and to examine variability between services . Design : A time-sampling strategy in which therapists recorded their face-to-face interventions with stroke patients during 12 weeks over a total of 17 months . Setting s and subjects : Six occupational therapists and seven physiotherapists from four services ( three day hospitals and one domiciliary stroke rehabilitation service ) recorded interventions with 89 stroke patients recruited to a larger r and omized controlled trial . Main outcome measures : Frequencies of use of interventions , together with other details about delivery of therapy , were recorded using a data collection booklet and coding system design ed by the participating therapists . Results : The median treatment time for a session was 45 minutes . The most frequently recorded components of physiotherapy intervention were ‘ walking ’ , ‘ st and ing balance ’ and ‘ upper limb movement pattern ’ , and of occupational therapy ‘ physical function ’ , ‘ social and leisure activities ' and ‘ other ’ . There was variability between the services in terms of median treatment time , use of intervention codes , frequency of treatment sessions , amount of time spent working with assistance and amount of group work . Conclusions : The findings support the view that occupational therapy and physiotherapy with people with stroke are not homogeneous activities , and vary between therapists and services . Recommendations include further development of the tool , and use of other method ologies to explore the process and nature of stroke rehabilitation Ninety seven patients with stroke who had participated in a r and omised trial of conventional physical therapy nu an enhanced therapy for arm function were followed up at one year . Despite the emphasis of the enhanced therapy approach on continued use of the arm in everyday life , the advantage seen for some patients with enhanced therapy at six months after stroke had diminished to a non-significant trend by one year . This was due to some late improvement in the conventional therapy group whereas the enhanced therapy group remained static or fell back slightly . It is recommended that trials should be conducted comparing very intensive therapy for the arm with controls without treatment . This would provide a model of the effects of therapy on intrinsic neural recovery that would be relevant to all areas of neurological rehabilitation Previous research on stroke rehabilitation has not established whether increase in physical therapy lead to better intrinsic recovery from hemiplegia . A detailed study was carried out of recovery of arm function after acute stroke , and compares orthodox physiotherapy with an enhanced therapy regime which increased the amount of treatment as well as using behavioural methods to encourage motor learning . In a single-blind r and omised trial , 132 consecutive stroke patients were assigned to orthodox or enhanced therapy groups . At six months after stroke the enhanced therapy group showed a small but statistically significant advantage in recovery of strength , range and speed of movement . This effect seemed concentrated amongst those who had a milder initial impairment . More work is needed to discover the reasons for this improved recovery , and whether further development of this therapeutic approach might offer clinical ly significant gains for some patients BACKGROUND AND PURPOSE Many patients have impaired arm function after stroke , for which they receive physiotherapy . The aim of the study was to determine whether increasing the amount of physiotherapy early after stroke improved the recovery of arm function and to compare the effects of this therapy when administered by a qualified therapist or a trained , supervised assistant . The physiotherapy followed a typical British approach , which is Bobath derived . Ten hours of additional therapy were given over a 5-week period . METHODS The study design was a single-blind , r and omized , controlled trial . Stroke patients were recruited from those admitted to the hospital in the 5 weeks after stroke . They were r and omly allocated to routine physiotherapy , additional treatment by a qualified physiotherapist , or additional treatment by a physiotherapy assistant . Outcome was assessed after 5 weeks of treatment and at 3 and 6 months after stroke on measures of arm function and of independence in activities of daily living . RESULTS There were 282 patients recruited to the study . The median initial Barthel score was 6.5 , and the median age of the patients was 73 years . The median initial Rivermead Motor Assessment Arm score was 1 . There were no significant differences between the groups at r and omization or on any of the outcome measures . Only half of the patients allocated to the 2 additional-therapy groups completed the program . CONCLUSIONS This increase in the amount of physiotherapy for arm impairment with a typical British approach given early after stroke did not significantly improve the recovery of arm function in the patients studied . A number of other studies of interventions aim ed at rehabilitation of arm function have reported positive results . Such findings may have been due to the content of these interventions , to the greater intensity of the interventions , or to the selection of patients to whom the treatments were applied Abstract Objective : To establish if a brief programme of domiciliary occupational therapy could improve the recovery of  patients with stroke discharged from hospital . Design : Single blind r and omised controlled trial . Setting : Two hospital sites within a UK teaching hospital . Subjects : 138 patients with stroke with a definite plan for discharge home from hospital . Intervention : Six week domiciliary occupational therapy or routine follow up . Main outcome measures : Nottingham extended activities of daily living score and “ global outcome ” ( deterioration according to the Barthel activities of daily living index , or death ) . Results : By eight weeks the mean Nottingham extended activities of daily living score in the intervention group was 4.8 points ( 95 % confidence interval −0.5 to 10.0 , P=0.08 ) greater than that of the control group . Overall , 16 ( 24 % ) intervention patients had a poor global outcome compared with 30 ( 42 % ) control patients ( odds ratio 0.43 , 0.21 to 0.89 , P=0.02 ) . These patterns persisted at six months but were not statistically significant . Patients in the intervention group were more likely to report satisfaction with a range of aspects of services . Conclusion : The functional outcome and satisfaction of patients with stroke can be improved by a brief occupational therapy programme carried out in the patient 's home immediately after discharge . Major benefits may not , however , be sustained 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 OBJECTIVE To evaluate the immediate and retention effects of a 4-week training program on the performance of locomotor-related tasks in chronic stroke . DESIGN R and omized , controlled pilot study with 2-month follow-up . SETTING Rehabilitation center . SUBJECTS A convenience sample consisting of 12 chronic stroke subjects was used . Subjects were r and omly assigned to the experimental or the control group . Three subjects withdrew from the study . INTERVENTION Both experimental and control groups participated in exercise classes three times a week for 4 weeks . The exercise class for the experimental group focused on strengthening the affected lower limb and practicing functional tasks involving the lower limbs , while the control group practice d upper-limb tasks . MAIN OUTCOME MEASURES Lower-limb function was evaluated by measuring walking speed and endurance , peak vertical ground reaction force through the affected foot during sit-to-st and , and the step test . RESULTS The experimental group demonstrated significant immediate and retained ( 2-month follow-up ) improvement ( p < or = .05 ) compared with the control group in walking speed and endurance , force production through the affected leg during sit-to-st and , and the number of repetitions of the step test . CONCLUSION The pilot study provides evidence for the efficacy of a task-related circuit class at improving locomotor function in chronic stroke 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 BACKGROUND We investigated the effects of different intensities of arm and leg rehabilitation training on the functional recovery of activities of daily living ( ADL ) , walking ability , and dexterity of the paretic arm , in a single-blind r and omised controlled trial . METHODS Within 14 days after stroke onset , 101 severely disabled patients with a primary middle-cerebral-artery stroke were r and omly assigned to : a rehabilitation programme with emphasis on arm training ; a rehabilitation programme with emphasis on leg training ; or a control programme in which the arm and leg were immobilised with an inflatable pressure splint . Each treatment regimen was applied for 30 min , 5 days a week during the first 20 weeks after stroke . In addition , all patients underwent a basic rehabilitation programme . The main outcome measures were ability in ADL ( Barthel index ) , walking ability ( functional ambulation categories ) , and dexterity of the paretic arm ( Action Research arm test ) at 6 , 12 , 20 , and 26 weeks . Analyses were by intention to treat . FINDINGS At week 20 , the leg-training group ( n=31 ) had higher scores than the control group ( n=37 ) for ADL ability ( median 19 [ IQR 16 - 20 ] vs 16 [ 10 - 19 ] , p<0.05 ) , walking ability ( 4 [ 3 - 5 ] vs 3 [ 1 - 4 ] , p<0.05 ) , and dexterity ( 2 [ 0 - 56 ] vs 0 [ 0 - 2 ] , p<0.01 ) . The arm-training group ( n=33 ) differed significantly from the control group only in dexterity ( 9 [ 0 - 39 ] vs 0 [ 0 - 2 ] , p<0.01 ) . There were no significant differences in these endpoints at 20 weeks between the arm-training and leg-training groups . INTERPRETATION Greater intensity of leg rehabilitation improves functional recovery and health-related functional status , whereas greater intensity of arm rehabilitation results in small improvements in dexterity , providing further evidence that exercise therapy primarily induces treatment effects on the abilities at which training is specifically aim ed A r and omised single-blind controlled trial was design ed to determine whether intensity of therapy ( physiotherapy and occupational therapy ) shortened length of stay for patients in a rehabilitation unit . Patients were under 65 , primarily with stroke , but also with other conditions such as traumatic brain injury , and multiple sclerosis . The experimental group were timetabled to receive 67 % more therapy in any given week , than the control group . After controlling for confounders and case mix ( as expressed by type of therapy required ) patients in the experimental group showed a significant 14-day reduction in length of stay ( < 0.01 ) . Concurrently average length of stay was increased for both groups by 16 days due to delays in discharge Objective : The objective was to investigate the effect of increased intensity of rehabilitation therapy provided to brain-injured subjects on the rate at which independence was regained and the duration of hospital admission . Design : A two-centre , prospect i ve , controlled study with r and om allocation to groups . Setting : Two district general hospitals on the south coast of Engl and . Subjects : Fifty-six people with moderate and severe head injury consecutively admitted to Southampton and Poole hospitals between June 1995 and September 1997 . Interventions : Increased intensity of rehabilitation therapy input without change in content . Results : Subjects receiving more intensive therapy made more rapid progress and were discharged home sooner . The different intensities of therapy employed in this study showed no evidence of a ‘ ceiling ’ effect and the ‘ intervention group ’ made significantly more rapid progress on tests of dependency during the period of admission . A clear response to increased therapy input was seen in one of the centres with more rapid functional improvement and a shorter length of hospital stay . This centre already had more therapy and better community facilities . No such benefits were seen at the other centre where the intervention group had a longer hospital stay than the routine group . Conclusion : Increasing the hours per week of therapy given to adults recovering from brain injury in hospital can accelerate the rate of recovery of personal independence and result in their being discharged from hospital sooner . Increased rehabilitation therapy after brain injury is associated with enhanced functional recovery and shorter hospital stay if provided in the context of an integrated service that can provide ongoing community support . There is no evidence of any ceiling effect of therapeutic intensity beyond which no further response is observed Objective : To evaluate the effects of leisure therapy and conventional occupational therapy ( OT ) on the mood , leisure participation and independence in activities of daily living ( ADL ) of stroke patients 6 and 12 months after hospital discharge . Design : Multicentre r and omized controlled trial . Setting and participants : Four hundred and sixty-six stroke patients from five UK centres . Main outcome measures : The General Health Question naire ( 12 item ) , the Nottingham Extended ADL Scale and the Nottingham Leisure Question naire , assessed by post  , with  telephone clarification . Results : Four hundred and forty ( 94 % ) and 426 ( 91 % ) subjects were alive at 6 and 12 months , respectively . Three hundred and seventy-four ( 85 % of survivors ) and 311 ( 78 % of survivors ) responded at 6 and 12 month follow-up respectively . At six months and compared to the control group , those allocated to leisure therapy had nonsignificantly better GHQ scores ( –1.2 : 95 % CI –2.9 , + 0.5 ) , leisure scores ( + 0.7 , 95 % CI –1.1 , + 2.5 ) and Extended ADL scores ( + 0.4 : 95 % CI –3.8 , + 4.5 ) : the ADL group had nonsignificantly better GHQ scores ( –0.1 : 95 % CI –1.8 , + 1.7 ) and Extended ADL scores ( + 1.4 : 95 % CI –2.9 , + 5.6 ) and nonsignificantly worse leisure scores ( –0.3 : 95 % CI –2.1 , + 1.6 ) . The results at 12 months were similar . Conclusion : In contrast to the findings of previous smaller trials , neither of the additional OT treatments showed a clear beneficial effect on mood , leisure activity or independence in ADL measured at 6 or 12 months Objective : To determine whether stroke patients referred to the Social Service occupational therapy service  would benefit from an enhanced service compared to the usual service . Design : R and omized controlled study allocating patients to the enhanced service or the usual service . Subjects : Stroke patients discharged home from hospital and referred to Social Service occupational therapy department . Outcome measures : The sections and total score from the Nottingham Extended Activities of Daily Living Scale ( EADL ) , the Barthel Index , the General Health Question naire ( GHQ ) and the number of pieces of equipment provided were analysed . Results : One hundred and eleven stroke patients were recruited to this study . Fifty-three were r and omly allocated to the enhanced service and 58 to the usual service . Patients receiving the enhanced service were seen more quickly after referral , for longer , and received significantly more visits ( p < 0.01 ) than those receiving the usual service . Three months after entry to the study the enhanced service group had better EADL ( p < 0.01 ) than the usual service group . This benefit remained significant in only the mobility section of the EADL at six months . Carers of the stroke patients in the enhanced group had lower GHQ scores ( p < 0.05 ) than those in the usual group at six months . Conclusions : This trial supports the use of domiciliary occupational therapy for stroke patients after discharge from hospital in terms of improvements in functional outcomes in the short term , but the long-term benefits remain unclear BACKGROUND Patients who have a stroke are not always admitted to hospital , and 22 - 60 % remain in the community , frequently without coordinated rehabilitation . We aim ed to assess the efficacy of an occupational therapy intervention for patients with stroke who were not admitted to hospital . METHODS In this single-blind r and omised controlled trial , consecutive stroke patients on a UK community register in Nottingham and Derbyshire were allocated r and omly to up to 5 months of occupational therapy at home or to no intervention ( control group ) 1 month after their stroke . The aim of the occupational therapy was to encourage independence in personal and instrumental activities of daily living . Patients were assessed on outcome measures at baseline ( before r and omisation ) and at 6 months . The primary outcome measure was the score on the extended activities of daily living ( EADL ) scale at 6 months . Other outcome measures included the Barthel index , the general health question naire 28 , the carer strain index , and the London h and icap scale . All assessment s were done by an independent assessor who was unaware of treatment allocation . The analysis included only data from completed question naires . FINDINGS 185 patients were included : 94 in the occupational therapy group and 91 in the control group . 22 patients were not assessed at 6 months . At follow-up , patients who had occupational therapy had significantly higher median scores than the controls on : the EADL scale ( 16 vs 12 , p<0.01 , estimated difference 3 [ 95 % CI 1 to 4 ] ) ; the Barthel index ( 20 vs 18 , p<0.01 , difference 1 , [ 0 - 1 ] ) ; the carer strain index ( 1 vs 3 , p<0.05 , difference 1 [ 0 to 2 ] ) ; and the London h and icap scale ( 76 vs 65 , p<0.05 , difference 7 , [ 0.3 to 13.5 ] ) . There were no significant differences on the general health question naire between the patient or carer . INTERPRETATION Occupational therapy significantly reduced disability and h and icap in patients with stroke who were not admitted to hospital OBJECTIVE --To determine whether the intervention of a physiotherapist improved mobility in patients seen more than one year after stroke . DESIGN --R and omised crossover trial comparing two groups offered intervention by a physiotherapist , one immediately after entry into the trial and the other after a delay of three months . The intervention consisted of identifying problems and offering advice and help to solve the problems . SETTING -- Patients ' homes in Oxfordshire . SUBJECTS-- Patients who had reduced mobility due to a stroke more than one year before entry ; 60 were recruited from a community stroke register and 34 in other ways . MAIN OUTCOME MEASURES --St and ard measures of mobility including gait speed , functional ambulation categories , the Nottingham extended activities of daily living index , and individual items from the Barthel activities of daily living index and the Frenchay activities index . Measures of manual dexterity , depression , and anxiety were used as controls . RESULTS --94 patients entered the trial and 49 were r and omised to immediate and 45 to delayed physiotherapy ; 89 were compared at the crossover point . At r and omisation the two groups were comparable . At three months the group given early therapy showed an improvement in gait speed whereas the untreated group had declined ( differences of -3.9 v 6.4 s to walk 10 m ; p less than 0.01 ) ; between three and six months the group given delayed therapy showed improvement and the previously treated group declined ( differences of 6.5 v -3.9 s to walk 10 m ; p less than 0.01 ) . A 9 % ( 95 % confidence interval 0 % to 18 % ) decrease in time taken to walk 10 m was associated with treatment and a 12 % ( 2 % to 19 % ) increase when patients were untreated . Other measures did not change significantly . CONCLUSION --Intervention of an experienced physiotherapist late after stroke specifically improves mobility , albeit by a small amount , but the effects do not seem to be maintained , perhaps because there is an underlying decline in mobility in these patients . Gait speed offers a simple and sensitive measure of outcome Objective : To discover if the provision of additional  inpatient physiotherapy after stroke speeds the recovery of mobility . Design : A multisite single-blind r and omized controlled trial ( RCT ) comparing the effects of augmented physiotherapy input with normal input on the recovery of mobility after stroke . Setting : Three rehabilitation hospitals in North Glasgow , Scotl and . Subjects : Patients admitted to hospital with a clinical diagnosis of stroke , who were able to tolerate and benefit from mobility rehabilitation .  Intervention : We aim ed to provide double the amount of physiotherapy to the augmented group . Main measures : Primary outcomes were mobility milestones ( ability to st and , step and walk ) , Rivermead Mobility Index ( RMI ) and walking speed . Results : Seventy patients were recruited . The augmented therapy group received more direct contact with a physiotherapist ( 62 versus 35 minutes per weekday ) and were more active ( 8.0 % versus 4.8 % time st and ing or walking ) than normal therapy controls . The augmented group tended to achieve independent walking earlier ( hazard ratio 1.48 , 95 % confidence interval 0.90–2.43 ; p=0.12 ) and had higher Rivermead Mobility Index scores at three months ( mean difference 1.6 ; 0.1 to 3.3 ; p=0.068 ) but these differences did not reach statistical significance . There was no significant difference in any other outcome . Conclusions : A modest augmented physiotherapy programme result ed in patients having more direct physiotherapy time and being more active . The inability to show statistically significant changes in outcome measures could indicate either that this intervention is ineffective or that our study could not detect modest changes A r and omized controlled pilot trial was conducted to estimate the effects of early , intensive , gait-focused physical therapy on ambulatory ability in acute , stroke patients . Twenty-seven patients with middle cerebral artery infa rct of thromboembolic origin confirmed by computed axial tomography scan were stratified and r and omly assigned to the experimental group , to a control group that received early , intensive and conventional therapy , or to a group receiving routine conventional therapy that started later and was not intense . Assessment s at entry , six weeks , and three and six months by independent evaluators permitted comparisons with reference to clinical measures of motor performance , balance , and functional capacity , and laboratory measures of gait movements . Group results at six weeks demonstrated that gait velocity was similar in the two conventional groups thereby eliminating the timing of the interventions as an important factor . At that point , gait velocity was faster in the experimental group . The difference translated into a moderate effect size of 0.58 . The time dedicated to gait training but not to total therapy time was correlated ( rs = 0.63 ) to gait velocity . This effect disappeared at three and six months after stroke . These pilot results justify planning a large trial to test the effectiveness of a therapeutic protocol that focuses on early and intense gait therapy in an effort to facilitate early ambulation following stroke BACKGROUND AND PURPOSE The effects of different duration s of rehabilitation sessions for the upper extremities ( UEs ) and lower extremities ( LEs ) on the recovery of interlimb coordination in hemiplegic gait in patients who have had a stroke were investigated . SUBJECTS AND METHODS Fifty-three subjects who had strokes involving their middle cerebral arteries were assigned to rehabilitation programs with ( 1 ) an emphasis on the LEs , ( 2 ) an emphasis on the paretic UE , or ( 3 ) a condition in which the paretic arm ( UE ) and leg ( LE ) were immobilized with an inflatable pressure splint ( control treatment ) . The 3 treatment regimens were applied for 30 minutes , 5 days a week , during the first 20 weeks after onset of stroke . All subjects also participated in a rehabilitation program 5 days a week that consisted of 15 minutes of UE exercises and 15 minutes of LE exercises in addition to a weekly 11/2-hour session of training in activities of daily living . A repeated- measures design was used . Differences among the 3 treatment regimens were evaluated in terms of comfortable and maximal walking speeds . In addition , mean continuous relative phase ( CRP ) between paretic arm and leg ( PAL ) movements and nonparetic arm and leg ( NAL ) movements and st and ard deviations of CRP of both limb pairs as a measurement of stability ( variability ) were evaluated . RESULTS Comfortable walking speed improved in the group that received interventions involving the LEs compared with the group that received interventions involving the UEs and the group that received the control treatment . No differences among the 3 treatment conditions were found for the mean CRP of NAL and PAL as well as the st and ard deviation of CRP of both limb pairs . DISCUSSION AND CONCLUSION With the exception of an improved comfortable walking speed as a result of a longer duration of rehabilitation sessions , no differential effects of duration of rehabilitation sessions for the LEs and UEs on the variable we measured related to hemiplegic gait were found . Increasing walking speed , however , result ed in a larger mean CRP for both limb pairs , with increased stability and asymmetry of walking , indicating that walking speed influences interlimb coordination in hemiplegic gait
BACKGROUND AND PURPOSE To present a systematic review of studies that addresses the effects of intensity of augmented exercise therapy time ( AETT ) on activities of daily living ( ADL ) , walking , and dexterity in patients with stroke .