A progressive exercise and structured advice program does not improve activity more than structured advice alone following a distal radial fracture: a multi-centre, randomised trial. The Role of Caregiver Involvement in Upper-Limb Treatment in Individuals With Subacute Stroke The role of physiotherapy and clinical predictors of outcome after fracture of the distal radius. Randomized Trial of a Robotic Assistive Device for the Upper Extremity During Early Inpatient Stroke Rehabilitation Paretic Upper-Limb Strength Best Explains Arm Activity in People With Stroke Walking tolerance of patients recovering from hip fracture: a phase I trial Home-based multicomponent rehabilitation program for older persons after hip fracture: a randomized trial. Wristband Accelerometers to motiVate arm Exercise after Stroke (WAVES): study protocol for a pilot randomized controlled trial Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. Robotic-assisted rehabilitation of the upper limb after acute stroke. The inflammatory response to upper and lower limb exercise and the effects of exercise training in patients with claudication. Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction Exercise intervention to prevent falls and enhance mobility in community dwellers after stroke: a protocol for a randomised controlled trial Stochastic Resonance Stimulation for Upper Limb Rehabilitation Poststroke Combined transcranial direct current stimulation and home-based occupational therapy for upper limb motor impairment following intracerebral hemorrhage: a double-blind randomized controlled trial Effectiveness of a physical exercise intervention program in improving functional mobility in older adults after hip fracture in later stage rehabilitation: protocol of a randomized clinical trial (REATIVE Study) [The effect of neurorehabilitation on the functional state and muscle tone of upper limb in patients after ischaemic stroke]. Upper-limb robot-assisted therapy in rehabilitation of acute stroke patients: focused review and results of new randomized controlled trial. Randomized placebo-controlled trial of brisk walking in the prevention of postmenopausal osteoporosis. EMG feedback treatment of upper limb in hemiplegic stroke patients: a pilot study. Virtual reality for the rehabilitation of the upper limb motor function after stroke: a prospective controlled trial Television, computer, and video viewing; physical activity; and upper limb fracture risk in children: a population-based case control study. Modified Constraint‐Induced Movement Therapy is a feasible and potentially useful addition to the Community Rehabilitation tool kit after stroke: A pilot randomised control trial Home exercise programmes supported by video and automated reminders compared with standard paper-based home exercise programmes in patients with stroke: a randomized controlled trial Bilateral and unilateral movement training on upper limb function in chronic stroke patients: A TMS study Early rehabilitation reduces the onset of complications in the upper limb following breast cancer surgery. Impairments, activity limitations and participation restrictions 6 and 12 months after breast cancer operation. Robot training enhanced motor outcome in patients with stroke maintained over 3 years Upper limb motor rehabilitation impacts white matter microstructure in multiple sclerosis Effects of exercise training on limb blood flow in patients with reduced ventricular function. A novel robot device in rehabilitation of post-stroke hemiplegic upper limbs Mobility training after hip fracture: a randomised controlled trial. How should we train the upper limbs? A multidisciplinary intervention program improved the outcome after hip fracture for people with dementia--subgroup analyses of a randomized controlled trial. Botulinum Toxin for the Upper Limb After Stroke (BoTULS) Trial: Effect on Impairment, Activity Limitation, and Pain
QUESTION Does a program of exercise and structured advice implemented during the rehabilitation phase following a distal radial fracture achieve better recovery of upper limb activity than structured advice alone ? DESIGN A phase I/II , multi-centre , r and omised , controlled trial with concealed allocation , assessor blinding and intention-to-treat analysis . PARTICIPANTS Thirty-three adults ( 25 female , mean age 54 years ) following distal radial fracture managed in a cast . INTERVENTION The experimental intervention was a 6-week program of progressive exercise and structured advice implemented over three consultations by a physiotherapist . The control intervention was a program of structured advice only , delivered by a physiotherapist over three consultations . OUTCOME MEASURES The primary outcome was upper limb activity limitations , assessed by the Patient-Rated Wrist Evaluation and the shortened version of the Disabilities of the Arm , Shoulder and H and outcome measure ( QuickDASH ) . The secondary outcomes were wrist range of movement , grip strength and pain . All measures were completed at baseline ( week 0 ) , after the intervention ( week 7 ) and at 6 months ( week 24 ) . RESULTS There were no significant between-group differences in upper limb activity as measured by the Patient-Rated Wrist Evaluation at week 7 and week 24 assessment s ( mean difference -4 units , 95 % CI -10 to 2 ; mean difference 0 units , 95 % CI -3 to 3 , respectively ) , or QuickDASH at week 7 and week 24 assessment s ( mean difference -5 units , 95 % CI -16 to 6 ; mean difference 0.3 units , 95 % CI -6 to 7 , respectively ) . The secondary outcomes did not demonstrate any significant between-group effects . CONCLUSION The prescription of exercise in addition to a structured advice program over three physiotherapy consultations may convey no extra benefit following distal radial fracture managed in a cast . TRIAL REGISTRATION ACTRN12612000118808 . [ Bruder AM , Shields N , Dodd KJ , Hau R , Taylor NF ( 2016 ) A progressive exercise and structured advice program does not improve activity more than structured advice alone following a distal radial fracture : a multi-centre , r and omised trial . Journal of Physiotherapy62 : 145 - 152 ] Background Initial severity of upper-limb motor impairment and exercise intensity are important predictors of improved upper-limb function during stroke rehabilitation . Initial severity of motor impairment , however , is not modifiable by rehabilitation , and increased one-on-one treatment is not always feasible . Alternative methods to increase intensity and improve upper-limb function are needed . Objective The purpose of this study was to examine  caregiver involvement in upper-limb treatment as a method to improve upper-limb function . Design This study was a secondary analysis of a multi-site r and omized controlled trial for upper-limb recovery during subacute inpatient stroke rehabilitation . Methods Data from 50 individuals with subacute stroke who were r and omly assigned to the experimental group ( upper-limb exercise )  were used for the analysis . Outcome variables were measured at baseline and at completion of the 4-week intervention . Group comparisons between participants with caregiver support and participants without caregiver support were done using an analysis of variance . Using the Fugl-Meyer Upper-Limb Motor Impairment Scale and time spent in treatment ( intensity ) as covariates , a multivariate regression analysis was performed to determine the additive value of caregiver support on upper-limb function , as measured by change scores on the Chedoke Arm and H and Activity Inventory and the Motor Activity Log . Results Group comparisons revealed that participants with caregiver support had improved upper-limb function compared with those without caregiver support and were more likely to increase the amount of time spent doing exercise . The multiple regression analysis showed that Fugl-Meyer score , treatment intensity , and caregiver support were significant predictors of upper-limb improvement ( R2=.240–.292 ) . In the regression models , caregiver support accounted for 5 % to 9 % of upper-limb improvement . Limitations Support was coded as a dichotomous variable , and thus the degree of support or qualitative nature of support was not captured . Conclusions Involvement of caregivers was a determinant of improved upper-limb function over and above initial severity of motor impairment and exercise intensity . Further research is needed to determine the optimal qualitative and quantitative elements of caregiver involvement in stroke rehabilitation in order to maximize results The capacity for physiotherapy to improve the outcome after fracture of the distal radius is unproven . We carried out a r and omised controlled trial on 96 patients , comparing conventional physiotherapy with a regime of home exercises .  The function of the upper limb was assessed at the time of removal of the plaster cast and at three and six months after injury . Factors which may predict poor outcome in these patients were sought . Grip strength and h and function did not significantly differ between the two groups . Flexion and extension of the wrist were the only movements to improve with physiotherapy at six months ( p = 0.001 ) . Predictors of poor functional outcome were malunion and impaired function before the fracture . These patients presented with pain , decreased rotation of the forearm and low functional scores at six weeks . Our study has shown that home exercises are adequate rehabilitation after uncomplicated fracture of the distal radius , and routine referral for a course of physiotherapy should be discouraged . The role of physiotherapy in patients at high risk of a poor outcome requires further investigation Background . A recent Cochrane Review showed that early robotic training of the upper limb in stroke survivors can be more effective than other interventions when improving activities of daily living involving the arm function is the aim of therapy . Objective . We tested for efficacy of the study a protocol which involved the use of the NeReBot therapy in partial substitution of st and ard upper limb rehabilitation in post – acute stroke patients . Methods . In this dose-matched , r and omized controlled clinical trial , 34 hemiparetic participants with movement against gravity in shoulder , elbow , and wrist muscle groups were enrolled within 15 days of the onset of stroke . All participants received a total daily rehabilitation treatment for 120 minutes , 5 days per week for 5 weeks . The control group received st and ard therapy for the upper limb . The experimental group received st and ard therapy ( 65 % of exercise time ) associated with robotic training ( 35 % of exercise time ) . Muscle tone ( Modified Ashworth Scale ) , strength ( Medical Research Council ) , and synergism ( Fugl-Meyer motor scores ) were measured at impairment level , whereas dexterity ( Box and Block Test and Frenchay Arm Test ) and activities of daily living ( Functional Independence Measure ) were measured at activity level . All assessment s were performed at baseline , at the end of therapy ( time T1 ) , at 3 months ( time T2 ) , and at 7 months ( time T3 ) after entry . All between-group analyses were tested using nonparametric test with Bonferroni ’s adjustments for multiple testing . Results . No significant between-group differences were found with respect to demographic characteristics , motor , dexterity , and ADLs at baseline , postintervention ( T1 ) and at follow-up ( T2 and T3 ) . Conclusions . The robot therapy by NeReBot did not lead to better outcomes compared with conventional inpatient rehabilitation Background and Purpose The purpose of this study was to determine the relationship among variables of upper-limb impairment , upper-limb performance in activities of daily living ( activity ) , and engagement in life events and roles ( participation ) in people with chronic stroke . Subjects The subjects were 93 community-dwelling individuals with stroke ( ≥1 year ) . Methods This study , which was conducted in a tertiary rehabilitation center , used a cross-sectional design . The main measures of impairment were the Modified Ashworth Scale , h and held dynamometry , sensory testing ( monofilaments ) , and the Brief Pain Inventory .  The main measures of activity were the  Chedoke Arm and H and Activity Inventory ( CAHAI ) and the Motor Activity Log ( MAL ) . The main measure of participation was the Reintegration to Normal Living ( RNL ) Index . Results Paretic upper-limb strength ( force-generating capacity ) ( r=.89 , P<.01 ) , grip strength ( r=.69 , P<.01 ) , and tone ( resistance to passive movement ) ( r=−.80 , P<.01 ) were the impairment variables that were most strongly related to activity . Tone ( r=−.23 , P<.05 ) and CAHAI scores ( r=.22 , P<.05 ) had a significant , but weak , relationship to participation . Upper-limb strength accounted for 87 % of the variance of the CAHAI scores and 78 % of the variance of the MAL scores . In the participation models , tone and CAHAI scores accounted for 5 % of the variance of the RNL Index scores . Discussion and Conclusion Paretic upper-limb strength had the strongest relationship with variables of activity and best explained upper-limb performance in activities of daily living . Grip strength , tone , and sensation also were factors of upper-limb performance in activities of daily living . Increased tone and upper-limb performance in activities of daily living had a weak relationship with participation Abstract Purpose : To find out how much physical activity in the form of walking can be tolerated by adults admitted for inpatient rehabilitation after hip fracture . Method : Using a phase I dose – response design , in addition to usual scheduled rehabilitation care  participants without cognitive impairment were supervised to walk for a prescribed length of time on 5 consecutive days . Doses started at 3 min and were escalated when three participants successfully completed a dose . Secondary outcomes included physical activity and the Ambulatory Self-Confidence Question naire ( ASCQ ) . Results : The maximum tolerated dose of  walking  for the 13 participants ( 4 men and 9 women ; mean age 81 years , SD 10 ) was 6 min . At 10 min only 1 of 5 participants was able to complete the dose . The main reason for not tolerating the prescribed dose was fatigue . Participants had relatively low levels of daily physical activity ( mean 507 steps/day ) , and lacked confidence in their walking ( ASCQ mean 4.6 ) . Conclusion : Physical activity guidelines for older people are not appropriate for patients in active inpatient rehabilitation recovering from hip fracture where other factors such as fatigue may limit physical activity levels . These results can be taken into account when design ing rehabilitation programmes after hip fracture . Implication s for Rehabilitation Hip fracture is a common and serious fracture with ongoing disability for which people require inpatient rehabilitation to prepare for return to independent living in the community . The maximum tolerated dose of walking of 6 minutes suggests physical activity guidelines for older people are not applicable for those receiving active inpatient rehabilitation after hip fracture . The maximum tolerated dose of walking of 6 minutes during inpatient rehabilitation suggests rehabilitation programmes be structured to allow adequate time for recovery OBJECTIVE To determine whether a home-based systematic multicomponent rehabilitation strategy leads to improved outcomes relative to usual care . DESIGN A r and omized controlled trial with 12 months of follow-up . SETTING General community ; 27 home care agencies . PARTICIPANTS Three hundred four nondemented persons at least 65 years of age who underwent surgical repair of a hip fracture at two hospitals in New Haven , CT , and returned home within 100 days . INTERVENTION Systematic multicomponent rehabilitation strategy addressing both modifiable physical impairments ( physical therapy ) and activities of daily living ( ADL ) disabilities ( functional therapy ) versus usual care . MAIN OUTCOME MEASURES A battery of self-report and performance-based measures of physical and social function . RESULTS There was no significant difference in the proportion of participants in the two groups who recovered to prefracture levels in self-care ADL at 6 months ( 71 % vs 75 % ) or 12 months ( 74 % in both groups ) or in home management ADL at 6 months ( 35 % vs 44 % ) or 12 months ( 44 % vs 48 % ) . There also was no difference between the two groups in social activity levels , two timed mobility tasks , balance , or lower extremity strength at either 6 or 12 months . Compared with participants who received usual care , those in the multicomponent rehabilitation program showed slightly greater upper extremity strength at 6 months ( p = .04 ) and a marginally better gait performance ( p = .08 ) . CONCLUSIONS The systematic multicomponent rehabilitation program was no more effective in promoting recovery than usual home-based rehabilitation . Compared with previous cohorts , however , participants r and omized to usual care in our study received more rehabilitative and home care services and experienced a higher rate of recovery . This finding is important given the current pressures to reduce home services . The challenge is to determine the composition and duration of rehabilitation and home services that will ensure optimal functional recovery most efficiently in older persons after hip fracture Background Loss of upper limb function affects up to 85 % of acute stroke patients . Recovery of upper limb function requires regular intensive practise of specific upper limb tasks . To enhance intensity of practice interventions are being developed to encourage patients to undertake self-directed exercise practice . Most interventions do not translate well into everyday activities and stroke patients continue to find it difficult remembering integration of upper limb movements into daily activities . A wrist-worn device has been developed that monitors and provides ‘ live ’ upper limb activity feedback to remind patients to use their stroke arm in daily activities ( The CueS wristb and ) . The aim of this trial is to assess the feasibility of a multi-centre , observer blind , pilot r and omised controlled trial of the CueS wristb and in clinical stroke services . Methods / design This pilot r and omised controlled feasibility trial aims to recruit 60 participants over 15 months from North East Engl and . Participants will be within 3 months of stroke which has caused new reduced upper limb function and will still be receiving therapy . Each participant will be r and omised to an intervention or control group . Intervention participants will wear a CueS wristb and ( between 8 am and 8 pm ) providing “ live ” feedback towards pre-set movement goals through a simple visual display and vibration prompts whilst undertaking a 4-week upper limb therapy programme ( review ed twice weekly by an occupational/physiotherapist ) . Control participants will also complete the 4-week upper limb therapy programme but will wear a ‘ sham ’ CueS wristb and that monitors upper limb activity but provides no feedback . Outcomes will determine study feasibility in terms of recruitment , retention , adverse events , adherence and collection of descriptive clinical and accelerometer motor performance data at baseline , 4 weeks and 8 weeks . Discussion The WAVES study will address an important gap in the evidence base by reporting the feasibility of undertaking an evaluation of emerging and affordable technology to encourage impaired upper limb activity after stroke . The study will establish whether the study protocol can be supported by clinical stroke services , thereby informing the design of a future multi-centre r and omised controlled trial of clinical and cost-effectiveness . Trial registration IS RCT N:82306027 . Registered 12 July 2016 BACKGROUND Multiple sclerosis ( MS ) is a major cause of chronic , neurological disability , with a significant long-term disability burden , often requiring comprehensive rehabilitation . OBJECTIVES To systematic ally evaluate evidence from published Cochrane Review s of clinical trials to summarise the evidence regarding the effectiveness and safety of rehabilitation interventions for people with MS ( pwMS ) , to improve patient outcomes , and to highlight current gaps in knowledge . METHODS We search ed the Cochrane Data base of Systematic Review s up to December 2017 , to identify Cochrane Review s that assessed the effectiveness of organised rehabilitation interventions for pwMS . Two review ers independently assessed the quality of included review s , using the Revised Assessment of Multiple Systematic Review s ( R-AMSTAR ) tool , and the quality of the evidence for reported outcomes , using the GRADE framework . MAIN RESULTS Overall , we included 15 review s published in the Cochrane Library , comprising 164 r and omised controlled trials ( RCTs ) and four controlled clinical trials , with a total of 10,396 participants . The included review s evaluated a wide range of rehabilitation interventions , including : physical activity and exercise therapy , hyperbaric oxygen therapy ( HBOT ) , whole-body vibration , occupational therapy , cognitive and psychological interventions , nutritional and dietary supplements , vocational rehabilitation , information provision , telerehabilitation , and interventions for the management of spasticity . We assessed all review s to be of high to moderate method ological quality , based on R-AMSTAR criteria .Moderate- quality evidence suggested that physical therapeutic modalities ( exercise and physical activities ) improved functional outcomes ( mobility , muscular strength ) , reduced impairment ( fatigue ) , and improved participation ( quality of life ) . Moderate- quality evidence suggested that inpatient or outpatient multidisciplinary rehabilitation programmes led to longer-term gains at the levels of activity and participation , and interventions that provided information improved patient knowledge . Low-qualitty evidence suggested that neuropsychological interventions , symptom-management programmes ( spasticity ) , whole body vibration , and telerehabilitation improved some patient outcomes . Evidence for other rehabilitation modalities was inconclusive , due to lack of robust studies . AUTHORS ' CONCLUSIONS The evidence suggests that regular specialist evaluation and follow-up to assess the needs of patients with all types of MS for appropriate rehabilitation interventions may be of benefit , although the certainty of evidence varies across the different types of interventions evaluated by the review s. Structured , multidisciplinary rehabilitation programmes and physical therapy ( exercise or physical activities ) can improve functional outcomes ( mobility , muscle strength , aerobic capacity ) , and quality of life . Overall , the evidence for many rehabilitation interventions should be interpreted cautiously , as the majority of included review s did not include data from current studies . More studies , with appropriate design , which report the type and intensity of modalities and their cost-effectiveness are needed to address the current gaps in knowledge OBJECTIVE To investigate whether early therapy with a novel robotic device can reduce motor impairment and enhance functional recovery of poststroke patients with hemiparetic and hemiplegic upper limb . DESIGN A single-blind r and omized controlled trial , with an 8-month follow-up . SETTING Neurologic department and rehabilitation hospital . PARTICIPANTS Thirty-five patients with acute ( < or = 1 wk of onset ) , unilateral , ischemic embolic , or thrombotic stroke . INTERVENTIONS Patients of both groups received the same dose and length per day of st and ard poststroke multidisciplinary rehabilitation . Patients were r and omly assigned to 2 groups . The experimental group ( n=17 ) received additional early sensorimotor robotic training , 4 hours a week for 5 weeks ; the control group ( n=18 ) was exposed to the robotic device , 30 minutes a week , twice a week , but the exercises were performed with the unimpaired upper limb . Training by robot consisted of peripheral manipulation of the shoulder and elbow of the impaired limb , correlated with visual stimuli . MAIN OUTCOME MEASURES The Fugl-Meyer Assessment ( FMA ) of upper-extremity function ( shoulder/elbow and coordination and wrist/h and subsections ) to measure each trained limb segment ; the Medical Research Council ( MRC ) score to measure the strength of muscle force during 3 actions : shoulder abduction ( MRC deltoid ) , elbow flexion ( MRC biceps ) , and wrist flexion ( MRC wrist flexors ) ; the FIM instrument and its motor component ; and the Trunk Control Test ( TCT ) and Modified Ashworth Scale ( MAS ) . RESULTS Compared with the patients in the control group , the experimental group showed significant gains in motor impairment and functional recovery of the upper limb after robot therapy , as measured by the MRC deltoid ( P < or = .05 ) and biceps ( P<.05 ) scores , the FMA for the proximal upper arm ( P<.05 ) , the FIM instrument ( P<.05 ) , and the FIM motor score ( P<.01 ) ; these gains were also sustained at the 3- and 8-month follow-up . The FMA and MRC wrist flexor test findings did not differ statistically either at the end of training or at the follow-up sessions . We found no significant differences in MAS and TCT in either group in any of the evaluations . No adverse effects occurred and the robotic approach was very well accepted . CONCLUSIONS Patients who received robotic therapy in addition to conventional therapy showed greater reductions in motor impairment and improvements in functional abilities . Robotic therapy may therefore effectively complement st and ard rehabilitation from the start , by providing therapeutic support for patients with poststroke plegic and paretic upper limb PURPOSE We have previously shown that a program of upper limb exercise training can induce significant improvements in walking distance in patients with claudication . This study assessed whether upper limb exercise avoids the systemic inflammatory responses associated with lower limb exercise and also whether the inflammatory response to acute lower limb exertion is modified by a program of supervised exercise training . METHODS Fifty-two patients with stable intermittent claudication were r and omized into two groups who underwent 6 weeks of supervised upper ( n = 26 ) or lower ( n = 26 ) limb cardiorespiratory exercise training . A parallel control group ( n = 15 ) was provided with lifestyle advice only . Neutrophil activation markers ( CD11b and CD66b ) and plasma levels of von Willebr and factor ( marker of endothelial damage ) in response to an acute bout of sustained upper and lower limb exercise were assessed before and after the period of training . Plasma levels of soluble E-selectin ( marker of endothelial activation ) were also determined before and after the training period . RESULTS An acute bout of sustained lower limb exercise significantly increased the intensity of CD11b and CD66b expression by peripheral blood neutrophils in all groups , whereas upper limb exercise had no effect . Resting neutrophil expression of CD11b and CD66b and circulating von Willebr and factor levels were unaffected by the training program , as were the inflammatory responses to an acute bout of sustained upper and lower limb muscular work , despite the fact that both training programs significantly increased walking distances . CONCLUSIONS These findings indicate that upper limb exercise training programs may offer certain advantages over currently prescribed lower limb programs . Our results show that exercising nonischemic muscles in a way that promotes improved cardiorespiratory function and walking capacity can avoid the potentially deleterious systemic inflammatory responses associated with lower limb exertion in patients with stable intermittent claudication Purpose : This study examined the role of anxiety and upper limb dysfunction , amongst other variables , as predictors of health related quality of life ( HRQOL ) 6 months after stroke . Method : Participants : Stroke survivors ( n = 85 ) who had previously participated in a r and omised controlled trial of a physiotherapy intervention .  Dependent variable : HRQOL – Nottingham Health Profile ( NHP ) . Predictor variables : Mood – Hospital Depression and Anxiety Scale ; Upper Limb Functioning - Action Research Arm Test ; Rivermead Motor Assessment ; Activities of Daily Living – Modified Barthel Index ; Clinical and demographic factors . Results : Anxiety and depression significantly predicted 49 % of variance in overall HRQOL ( p < 0.05 ) , but only anxiety significantly predicted NHP pain ( 13 % variance , p < 0.001 ) , emotional reactions ( 41 % variance , p < 0.001 ) , sleep ( 19 % variance , p = 0.02 ) and social isolation ( 23 % variance , p = 0.02 ) . Depression and anxiety together significantly predicted 30 % variance in energy level ( p < 0.001 ) . UL motor impairment and activities of daily living predicted 36 % of variance in NHP physical activity score ( p < 0.001 ) . Conclusions : This study indicates that where anxiety is assessed , it appears more important in determining HRQOL than depression . UL impairment and ADL independence predicted perceived physical activity . Management strategies for anxiety and therapy for UL recovery long after stroke onset are likely to benefit perceived HRQOL . Implication s for Rehabilitation Anxiety is a major predictor of quality of life six months after stroke . Post-stroke anxiety should be routinely assessed in rehabilitation . Appropriate management strategies for anxiety should occur during rehabilitation with follow-up into the chronic post-stroke period . Upper limb impairment is a stronger predictor of perceptions of physical activity than independence in activities daily living six months after stroke . Rehabilitation of the upper limb should continue into the chronic post-stroke period Background Stroke is the most common disabling neurological condition in adults . Falls and poor mobility are major contributors to stroke-related disability . Falls are more frequent and more likely to result in injury among stroke survivors than among the general older population . Currently there is good evidence that exercise can enhance mobility after stroke , yet ongoing exercise programs for general community-based stroke survivors are not routinely available . This r and omised controlled trial will investigate whether exercise can reduce fall rates and increase mobility and physical activity levels in stroke survivors . Methods and design Three hundred and fifty community dwelling stroke survivors will be recruited . Participants will have no medical contradictions to exercise and be cognitively and physically able to complete the assessment s and exercise program .  After the completion of the pre-test assessment , participants will be r and omly allocated to one of two intervention groups . Both intervention groups will participate in weekly group-based exercises and a home program for twelve months . In the lower limb intervention group , individualised programs of weight-bearing balance and strengthening exercises will be prescribed . The upper limb/cognition group will receive exercises aim ed at management and improvement of function of the affected upper limb and cognition carried out in the seated position . The primary outcome measures will be falls ( measured with 12 month calendars ) and mobility . Secondary outcome measures will be risk of falling , physical activity levels , community participation , quality of life , health service utilisation , upper limb function and cognition . Discussion This study aims to establish and evaluate community-based sustainable exercise programs for stroke survivors . We will determine the effects of the exercise programs in preventing falls and enhancing mobility among people following stroke . This program , if found to be effective , has the potential to be implemented within existing community services . Trial registration The protocol for this study is registered with the Australian New Zeal and Clinical Trials Registry ( ACTRN12606000479505 ) Stein J , Hughes R , D ' And rea S , Therrien B , Niemi J , Krebs K , Langone L , Harry J : Stochastic resonance stimulation for upper limb rehabilitation poststroke . Objectives : Previous studies have shown that subthreshold electrical or mechanical noise can reduce the sensory threshold and impart short-term improvements in sensorimotor function . We undertook this study to examine the effects of combined subsensory electrical and vibratory stimulation in conjunction with exercise training on long-term motor performance . Design : Thirty subjects were recruited from adult community-dwelling stroke survivors with residual hemiparesis . Subjects were screened for residual motor ability using a functional task , and those who functioned below this level were excluded . All subjects had a history of a single unilateral ischemic or hemorrhagic stroke at least 6 mos before study entry and were not actively receiving occupational or physical therapy . Subjects were stratified by baseline upper extremity Fugl-Meyer ( UEFM ) ( more impaired [ 28–35 ] and less impaired [ 36–55 ] ) and were r and omized to one of two groups : treatment ( stochastic resonance stimulation [ plus over minus sign ] exercise : 15 subjects ) and control ( sham stimulation [ plus over minus sign ] exercise : 15 subjects ) . Results : No significant difference was found between the stochastic resonance treatment and control group in the UEFM or in any of the secondary measures . The combined group showed modest improvements in UEFM from baseline to completion of therapy ( mean improvement , 2.6 points ) ( P = 0.004 ) ; however , these improvements declined by 1-mo follow-up to 1.5 points ( P = 0.055 ) . No change in sensory function was detectable . Conclusions : Stochastic resonance therapy combined with occupational therapy was no more effective than occupational therapy alone in restoring sensorimotor performance . Other stochastic resonance stimulation montages or protocol s might prove more effective Abstract Purpose : To investigate the combined effect of transcranial direct current stimulation ( tDCS ) and home-based occupational therapy on activities of daily living ( ADL ) and grip strength , in patients with upper limb motor impairment following intracerebral hemorrhage ( ICH ) . Methods : A double-blind r and omized controlled trial with one-week follow-up . Patients received five consecutive days of occupational therapy at home , combined with either anodal ( n = 8) or sham ( n = 7 ) tDCS . The primary outcome was ADL performance , which was assessed with the Jebsen – Taylor test ( JTT ) . Results : Both groups improved JTT over time ( p < 0.01 ) . The anodal group improved grip strength compared with the sham group from baseline to post- assessment ( p = 0.025 ) . However , this difference was attenuated at one-week follow-up . There was a non-significant tendency for greater improvement in JTT in the anodal group compared with the sham group , from baseline to post- assessment ( p = 0.158 ) . Conclusions : Five consecutive days of tDCS combined with occupational therapy provided greater improvements in grip strength compared with occupational therapy alone . tDCS is a promising add-on intervention regarding training of upper limb motor impairment . It is well tolerated by patients and can easily be applied for home-based training . Larger studies with long-term follow-up are needed to further explore possible effects of tDCS in patients with ICH . Implication s for Rehabilitation Five consecutive days of tDCS combined with occupational therapy provided greater improvements in grip strength compared with occupational therapy alone . tDCS is well tolerated by patients and can easily be applied for home-based rehabilitation Background Hip fractures result ing from falls increase substantially with advancing age and less than half of older hip fracture survivors regain their former levels of mobility . There is increasing evidence that rehabilitation interventions with exercises that goes beyond the sub-acute phase or even in a later stage of care have a positive impact on various functional abilities . The purpose of this study is to determine if exercise program training for people who have suffered a fall-related hip fracture will improve functional mobility when compared with usual care . Methods A r and omized controlled trial with blinded assessors and intention-to-treat analysis will be undertaken . We will recruit 82 older adults , 60 years or over who have suffered a hip fracture due to a fall in the previous 6 to 24 months . Participants r and omized to the Intervention Group ( IG ) will undertake a physical exercise program involving progressive and challenging balance training and neuromuscular and functional training of the lower limbs , conducted at home by physiotherapists , once a week , lasting about one hour , in the first , second and third month after r and omization and will be taught to perform exercises at home , twice a week , using a booklet . Visits to monitor and progress the home exercise program will be conducted once a month , from the fourth to the sixth month and each 2 months until the end of the follow up at the 12th month , i.e. , a total of 18 sessions . Participants will receive monthly phone calls to encourage exercise adherence . The control group will receive usual care . The primary outcome will be mobility-related disability and participants will be assessed at baseline , and at 3 months , 6 and 12 months . Participants will receive monthly phone calls to ask about falls and exercise adherence . Adverse effects will be monitored . Discussion This study proposes a home-based exercise program , which may in part overcome some barriers for rehabilitation , such as difficulties with public transportation and lack of a caregiver to accompany older patients to sessions . If a positive effect is observed this program has the potential to be incorporated into the public health system and contribute to building a pathway of care for older people with hip fracture . Trial registration Clinical trials.gov Identifier : NCT02295527 UNLABELLED Rehabilitation of upper limb in patients after ischemic stroke is a major challenge for modern neurorehabilitation . Function of upper limb of patients after ischemic stroke returns on the end of the rehabilitation comparing with another parts of the body . Below presents two groups of patients after ischemic stroke who were rehabilitated with use of the following methods : kinesiotherapy combined with NDT- Bobath method and kinesiotherapy only . The aim of this study was to assess the impact of kinesiotherapy only and NDT- Bobath method combined with kinesiotherapy on the functional state and muscle tone of upper limb in patients after ischemic stroke . MATERIAL AND METHODS The study involved a group of 40 patients after ischemic stroke with motor control and muscle tone problems of upper limb . Patients were divided into two groups , each of them included 20 people . Upper limb in group I was rehabilitated with the use of kinesiotherapy exercise however group II with the use of kinesiotherapy exercise combined with NDT- Bobath method ( Neurodevelopmental Treatment Bobath ) . To evaluate the patients before and after rehabilitation muscle tone Asworth scale was used and to assess functional status Rivermead Motor Assessment ( RMAIII ) scale was used . RESULTS After 5 weeks of rehabilitation in group II in majority patients were observed decrease of muscle tone and improvement in upper limb functional status . In group I the muscle tone were also decreased and functional status were better but in smaller impact than in II group . CONCLUSIONS Classical kinesiotherapy combined with the NDT-Bobath method gives better results in neurorehabilitation of upper limb than the use of kinesiotherapy exercises only in patients after ischemic stroke The successful motor rehabilitation of stroke patients requires early intensive and task-specific therapy . A recent Cochrane Review , although based on a limited number of r and omized controlled trials ( RCTs ) , showed that early robotic training of the upper limb ( i.e. , during acute or subacute phase ) can enhance motor learning and improve functional abilities more than chronic-phase training . In this article , a new subacute-phase RCT with the Neuro-Rehabilitation-roBot ( NeReBot ) is presented . While in our first study we used the NeReBot in addition to conventional therapy , in this new trial we used the same device in substitution of st and ard proximal upper-limb rehabilitation . With this protocol , robot patients achieved similar reductions in motor impairment and enhancements in paretic upper-limb function to those gained by patients in a control group . By analyzing these results and those of previous studies , we hypothesize a new robotic protocol for acute and subacute stroke patients based on both treatment modalities ( in addition and in substitution ) OBJECTIVE to evaluate the effects of brisk walking on bone mineral density in women who had suffered an upper limb fracture . DESIGN r and omized placebo-controlled trial . Assessment s of bone mineral density were made before and at 1 and 2 years after intervention . St and ardized and vali date d measures of physical capacity , self-rated health status and falls were used . SETTING district general hospital outpatient department . SUBJECTS 165 women drawn from local accident and emergency departments with a history of fracture of an upper limb in the previous 2 years . Women were r and omly allocated to intervention ( self-paced brisk walking ) or placebo ( upper limb exercises ) groups . INTERVENTION both groups were seen at 3-monthly intervals to assess progress , measure physical capacity and maintain enthusiasm . The brisk-walking group were instructed to progressively increase the amount and speed of walking in a manner that suited them . The upper limb exercise placebo group were asked to carry out a series of exercises design ed to improve flexibility and fine h and movements , appropriate for a past history of upper limb fracture . RESULTS drop-outs from both intervention and placebo groups were substantial ( 41 % ) , although there were no significant differences in bone mineral density , physical capacity or health status between drop-outs and participants . At 2 years , among those completing the trial , bone mineral density at the femoral neck had fallen in the placebo group to a greater extent than in the brisk-walking group [ mean net difference between intervention and placebo groups 0.019 g/cm2 , 95 % confidence interval ( CI ) -0.0026 to + 0.041 g/cm2 , P = 0.056 ] . Lumbar spine bone mineral density had increased to a similar extent ( + 0.017 g/cm2 ) in both groups . The cumulative risk of falls was higher in the brisk-walking group ( excess risk of 15 per 100 person-years , 95 % CI 1.4 - 29 per 100 person-years , P < 0.05 ) . There were no significant differences in clinical or spinal x-ray fracture risk or self-rated health status between intervention and placebo groups . CONCLUSION the promotion of exercise through brisk-walking advice given by nursing staff may have a small , but clinical ly important , impact on bone mineral density but is associated with an increased risk of falls . Self-paced brisk walking is difficult to evaluate in r and omized controlled trials because of drop-outs , placebo group exercise , limited compliance and lack of st and ardization of the duration and intensity of walking . Further work is needed to evaluate the best means of safely achieving increased activity levels in different groups , such as older women and those at high risk of fractures Poor prognosis for upper limb recovery of stroke survivors has not changed in at least 28 years ; only 4 % to 5 % of patients regain arm function during or after the active rehabilitation phase . This pilot study included 37 patients r and omly assigned to either an integrated behavioral-physical therapy treatment program including electromyographic feedback ( experimental group ) or a st and ard exercise physical therapy program of like duration and intensity ( control group ) . Both groups showed clinical ly significant improvements that exceeded previously reported experience . The experimental technique appears to be more effective when upper limb involvement is not severe in a late case , or when treatment is started early ( within 3 months poststroke ) in a severe case . The rehabilitation community should quickly investigate the improved prospect s of restoring a greater number of useful upper limbs in this often neglected group of hemiplegic patients Background Recent evidence has demonstrated the efficacy of Virtual Reality ( VR ) for stroke rehabilitation nonetheless its benefits and limitations in large population of patients have not yet been studied . Objectives To evaluate the effectiveness of non-immersive VR treatment for the restoration of the upper limb motor function and its impact on the activities of daily living capacities in post-stroke patients . Methods A pragmatic clinical trial was conducted among post-stroke patients admitted to our rehabilitation hospital . We enrolled 376 subjects who had a motor arm subscore on the Italian version of the National Institutes of Health Stroke Scale ( It-NIHSS ) between 1 and 3 and without severe neuropsychological impairments interfering with recovery . Patients were allocated to two treatments groups , receiving combined VR and upper limb conventional ( ULC ) therapy or ULC therapy alone . The treatment programs consisted of 2 hours of daily therapy , delivered 5 days per week , for 4 weeks . The outcome measures were the Fugl-Meyer Upper Extremity ( F-M UE ) and Functional Independence Measure ( FIM ) scales . Results Both treatments significantly improved F-M UE and FIM scores , but the improvement obtained with VR rehabilitation was significantly greater than that achieved with ULC therapy alone . The estimated effect size of the minimal difference between groups in F-M UE and FIM scores was 2.5 ± 0.5 ( P < 0.001 ) pts and 3.2 ± 1.2 ( P = 0.007 ) pts , respectively . Conclusions VR rehabilitation in post-stroke patients seems more effective than conventional interventions in restoring upper limb motor impairments and motor related functional abilities . Trial registration Italian Ministry of Health IRCCS Research Programme UNLABELLED The effect of physical activity on upper limb fractures was examined in this population -based case control study with 321 age- and gender-matched pairs .  Sports participation increased fracture risk in boys and decreased risk in girls . Television viewing had a deleterious dose response association with wrist and forearm fractures while light physical activity was protective . INTRODUCTION The aim of this population -based case control study was to examine the association between television , computer , and video viewing ; types and levels of physical activity ; and upper limb fractures in children 9 - 16 years of age . MATERIAL S AND METHODS A total of 321 fracture cases and 321 r and omly selected individually matched controls were studied .  Television , computer , and video viewing and types and levels of physical activity were determined by interview-administered question naire . Bone strength was assessed by DXA and metacarpal morphometry . RESULTS In general , sports participation increased total upper limb fracture risk in boys and decreased risk in girls . Gender-specific risk estimates were significantly different for total , contact , noncontact , and high-risk sports participation as well as four individual sports ( soccer , cricket , surfing , and swimming ) . In multivariate analysis , time spent television , computer , and video viewing in both sexes was positively associated with wrist and forearm fracture risk ( OR 1.6/category , 95 % CI : 1.1 - 2.2 ) , whereas days involved in light physical activity participation decreased fracture risk ( OR 0.8/category , 95 % CI : 0.7 - 1.0 ) . Sports participation increased h and ( OR 1.5/sport , 95 % CI : 1.1 - 2.0 ) and upper arm ( OR 29.8/sport , 95 % CI : 1.7 - 535 ) fracture risk in boys only and decreased wrist and forearm fracture risk in girls only ( OR 0.5/sport , 95 % CI : 0.3 - 0.9 ) . Adjustment for bone density and metacarpal morphometry did not alter these associations . CONCLUSION There is gender discordance with regard to sports participation and fracture risk in children , which may reflect different approaches to sport . Importantly , television , computer , and video viewing has a dose-dependent association with wrist and forearm fractures , whereas light physical activity is protective . The mechanism is unclear but may involve bone-independent factors , or less likely , changes in bone quality not detected by DXA or metacarpal morphometry BACKGROUND / AIM The National Stroke Foundation recommends that Occupational Therapists use Constraint-Induced Movement Therapy ( CIMT ) with stroke survivors that experience an upper limb deficit .  CIMT involves constraining the unaffected upper limb coupled with intensive therapy . The aim of this study was to evaluate the feasibility and effectiveness of a modified , low intensity version of CIMT ( mCIMT ) provided within usual re sources of an Australian community rehabilitation setting . METHODS A pilot r and omised control trial ( n = 19 ) was conducted with stroke survivors referred for community rehabilitation . Participants were r and omly assigned to either mCIMT or usual care . Both groups received six one-hour outpatient Occupational Therapy sessions ( focussed on upper limb rehabilitation ) over a two-week period . The intervention group ( mCIMT ) were asked to wear a constraint device on their unaffected h and for 90 % of their waking hours and were provided with a home exercise program based on CIMT principles . Participants were included if they had some active upper limb movement , no significant cognitive deficits and sufficient balance . Outcome measures included upper limb function ( WMFT ) and participation ( MAL ) evaluated at baseline , immediately following the two-week intervention period and at four-week follow-up . RESULTS Only a very small proportion of patients met the eligibility criteria . There were no differences between groups , with the exception of a small increase in reported upper extremity use in functional tasks at post-intervention assessment when compared to the usual care group . CONCLUSIONS Modified CIMT can be applied to a typical Australian community rehabilitation setting , to treat upper limb deficits in stroke survivors . The re sources used for mCIMT largely equalled usual care , with no differences in outcomes , suggesting that the intervention is feasible and potentially beneficial . However , there were very few stroke survivors who met participation criteria , indicating that dem and for the intervention is limited Objective : To determine whether patients with stroke receiving rehabilitation for upper limb deficits using smart technology ( video and reminder functions ) demonstrate greater adherence to prescribed home exercise programmes and better functional outcomes when compared with traditional paper-based exercise prescription . Design : R and omized controlled trial comparing upper limb home exercise programmes supported by video and automated reminders on smart technology , with st and ard paper-based home exercise programmes . Setting : A community rehabilitation programme within a large metropolitan health service . Subjects : Patients with stroke with upper limb deficits , referred for outpatient rehabilitation . Interventions : Participants were r and omly assigned to the control ( paper-based home exercise programme ) or intervention group ( home exercise programme filmed on an electronic tablet , with an automated reminder ) . Both groups completed their prescribed home exercise programme for four weeks . Main measures : The primary outcome was adherence using a self-reported log book . Secondary outcomes were change in upper limb function and patient satisfaction . Results : A total of 62 participants were allocated to the intervention ( n = 30 ) and control groups ( n = 32 ) . There were no differences between the groups for measures of adherence ( mean difference 2 % , 95 % CI −12 to 17 ) or change in the Wolf Motor Function Test log transformed time ( mean difference 0.02 seconds , 95 % CI −0.1 to 0.1 ) . There were no between-group differences in how participants found instructions ( p = 0.452 ) , whether they remembered to do their exercises ( p = 0.485 ) , or whether they enjoyed doing their exercises ( p = 0.864 ) . Conclusions : The use of smart technology was not superior to st and ard paper-based home exercise programmes for patients recovering from stroke . This trial design was registered prospect ively with the Australian and New Zeal and Clinical Trials Register , ID : ACTRN 12613000786796 . http://www.anzctr.org.au/trial Search The use of activity-dependent interventions has shown some success in promoting recovery of upper limb function in chronic stroke patients . This study compared the neurophysiological and behavioural changes associated with two such rehabilitation protocol s : unilateral and bilateral movement training .  Twelve chronic stroke patients were r and omly assigned to the two training protocol s involving six daily practice sessions . Each session consisted of 50 trials of a dowel placement task performed either with both impaired and unimpaired arm moving synchronously ( bilateral training group ) or with only the impaired arm moving ( unilateral training ) . Kinematic measurements of upper limb movements were made in four unilateral test trials performed prior to and following each practice session . Functional assessment s of the impaired upper limb and neurophysiological assessment s , using transcranial magnetic stimulation ( TMS ) , of the affected and non-affected cortical hemispheres were made prior to and following the intervention sessions . Individuals receiving bilateral training showed a reduction in movement time of the impaired limb and increased upper limb functional ability compared to individuals receiving unilateral training . In some patients changes to upper limb function were associated with changes to the cortical representation of a target muscle in the non-affected hemisphere . Overall , these findings suggest that a short-term bilateral training intervention may be effective in facilitating upper limb motor function in chronic stroke patients BACKGROUND Breast cancer ( BC ) is currently the most frequent tumor in women . Through the years , BC management has evolved towards conservative surgery . However , even minimally invasive surgery can cause neuromotor and /or articular impairments which can lead to permanent damage , if not adequately treated . AIM To clinical ly evaluate upper ipsilateral limb function and the impact of certain post-surgical consequences arising after invasive or breast-conserving surgery for early BC , by intervening , or not intervening , with an early rehabilitation program . To investigate physical morbidity after sentinel ( SLND ) or axillary lymph node dissection ( ALND ) and after reconstructive surgery in the treatment of early BC . DESIGN Observational prospect i ve trial . SETTING Inpatient and outpatient treatment . POPULATION Eighty-three females participated in the study : 25 patients did not begin physiotherapy during hospitalization ( Group A ) , 58 patients received early rehabilitation treatment ( Group B ) . METHODS The patients of Groups A and B were compared with respect to the following criteria : shoulder-arm mobility , upper limb function , and presence of lymphedema . All patients were assessed at 15 - 30 , 60 and 180 days after surgery . RESULTS Statistically significant differences , in favor of Group B , were encountered at the 180-day follow-up visit , especially with respect to articular and functional limitation of the upper limb . CONCLUSION AND CLINICAL REHABILITATION IMPACT The results of the present study show that early assisted mobilization ( beginning on the first postoperative day ) and home rehabilitation , in conjunction with written information on pre caution ary hygienic measures to observe , play a crucial role in reducing the occurrence of postoperative side-effects of the upper limb OBJECTIVE To describe the impairments of upper body and limbs , activity limitations and participation restrictions 6 and 12 months after operation for breast cancer and to examine the impact of impairments on activity limitations . DESIGN A prospect i ve survey 6 and 12 months after operation . PATIENTS Ninety-six breast cancer patients . METHODS A question naire for assessing the impairments , activity limitations and participation restrictions was developed . RESULTS The most common impairments 6 months after operation were breast and axilla scar tightness , axilla oedema and neck-shoulder pain . At 12-month follow-up the breast scar tightness ( p=0.008 ) and axilla oedema ( p=0.023 ) decreased , and limb ache ( p=0.005 ) increased significantly . The most limiting impairments were axilla oedema and limb numbness 6 months after operation , and at 12-month follow-up axilla oedema . Lifting , carrying and reaching out caused worsening of impairments to more than half of the respondents at 6-month follow-up . Regression analysis showed that many impairments together were determinants of activity limitations and sleep impairment . Participation restrictions were constant . Respondents had not given up participation in activities in the home , but some had ab and oned leisure activities and felt that their work ability had decreased . CONCLUSION Impairments and their impact on activities were frequent and constant . There is an urgent need for developing rehabilitation protocol s for breast cancer patients Article abstract In an attempt to improve motor recovery of the upper limb after stroke , we added a robot ( MIT-Manus ) experience that provided additional goal -directed sensorimotor activity to st and ard rehabilitation treatments . The first trial produced a significant decrease in motor impairment in the upper limb for the treated group . In re-evaluating 12 of those 20 patients , nearly 3 years later , robot-trained patients showed further significant decreases in impairment measures of the affected limb . The groups were comparable at the start of the study Upper limb impairments can occur in patients with multiple sclerosis , affecting daily living activities ; however there is at present no definite agreement on the best rehabilitation treatment strategy to pursue . Moreover , motor training has been shown to induce changes in white matter architecture in healthy subjects . This study aim ed at evaluating the motor behavioral and white matter microstructural changes following a 2-month upper limb motor rehabilitation treatment based on task-oriented exercises in patients with multiple sclerosis . Thirty patients ( 18 females and 12 males ; age=43.3 ± 8.7 years ) in a stable phase of the disease presenting with mild or moderate upper limb sensorimotor deficits were r and omized into two groups of 15 patients each . Both groups underwent twenty 1-hour treatment sessions , three times a week . The " treatment group " received an active motor rehabilitation treatment , based on voluntary exercises including task-oriented exercises , while the " control group " underwent passive mobilization of the shoulder , elbow , wrist and fingers . Before and after the rehabilitation protocol s , motor performance was evaluated in all patients with st and ard tests . Additionally , finger motor performance accuracy was assessed by an engineered glove . In the same sessions , every patient underwent diffusion tensor imaging to obtain parametric maps of fractional anisotropy , mean diffusivity , axial diffusivity , and radial diffusivity . The mean value of each parameter was separately calculated within regions of interest including the fiber bundles connecting brain areas involved in voluntary movement control : the corpus callosum , the corticospinal tracts and the superior longitudinal fasciculi . The two rehabilitation protocol s induced similar effects on unimanual motor performance , but the bimanual coordination task revealed that the residual coordination abilities were maintained in the treated patients while they significantly worsened in the control group ( p=0.002 ) . Further , in the treatment group white matter integrity in the corpus callosum and corticospinal tracts was preserved while a microstructural integrity worsening was found in the control group ( fractional anisotropy of the corpus callosum and corticospinal tracts : p=0.033 and p=0.022 ; radial diffusivity of the corpus callosum and corticospinal tracts : p=0.004 and p=0.008 ) . Conversely , a significant increase of radial diffusivity was observed in the superior longitudinal fasciculi in both groups ( p=0.02 ) , indicating lack of treatment effects on this structure , showing damage progression likely due to a demyelination process . All these findings indicate the importance of administering , when possible , a rehabilitation treatment consisting of voluntary movements . We also demonstrated that the beneficial effects of a rehabilitation treatment are task-dependent and selective in their target ; this becomes crucial towards the implementation of tailored rehabilitative approaches BACKGROUND Among the factors that contribute to limiting exercise tolerance in chronic heart failure are reduced peripheral blood flow and impaired vasodilatory capacity . Exercise training improves vasodilatory capacity in normal subjects , but controlled studies of exercise training evaluating upper and lower limb blood flow rates have not been performed in patients with reduced ventricular function . Improved vasodilatory capacity could help explain how training increases exercise capacity in these patients . METHODS Twenty patients ( mean age 55 + /- 6 years ) with reduced left ventricular function ( mean ejection fraction 32 % + /- 6 % ) after a myocardial infa rct ion were r and omized to a 2-month  high-intensity residential rehabilitation program or to a control group and were monitored over the subsequent year . Both groups were treated according to current practice with angiotensin-converting enzyme inhibition therapy . Training began 1 month after myocardial infa rct ion . Baseline and postischemic flow rates were measured by plethysmography in both the upper and lower limbs 1 month , 3 months , and 1 year after the infa rct ion . Peak oxygen uptake ( VO2 ) and cardiac output were measured before and after training , and peak VO2 was determined again after 1 year . RESULTS After 2 months of training  peak VO2 increased 25 % , VO2 at the lactate threshold increased 40 % , and maximal cardiac output increased from 12.1 + /- 1.6 L/min to 13.9 + /- 2.4 L/min in the exercise group ( all p < 0.05 ) , whereas no differences were observed in the control group . At the 1-year follow-up no further increases in peak VO2 were noted in either group , but the higher value persisted in the trained group . However , changes in limb flow rates were poorly related to changes in both peak VO2 and maximal cardiac output . Improvements in baseline and postischemic flow rates occurred mainly in the lower limbs and were observed in the two groups to a similar degree . CONCLUSION Exercise training is highly effective in improving exercise capacity in patients with reduced ventricular function after myocardial infa rct ion . These improvements parallel an increase in maximal cardiac output , but they are unrelated to vasodilatory capacity . In patients with reduced ventricular function after myocardial infa rct ion , lower limb vasodilatory capacity improves gradually over the subsequent year , and these improvements occur irrespective of exercise training Background and aims : In this pilot study , we introduce the “ NeReBot ” , a novel robotic device design ed and programmed for clinical neurological applications . The aim of the study was to test whether additional sensorimotor training of paralyzed or paretic upper limbs , delivered by NeReBot , enhanced motor and functional outcome in stroke patients . Methods : Twenty patients with post-stroke hemiparesis or hemiplegia received st and ard post-stroke multidisciplinary rehabilitation , and were r and omly assigned either to exposure to the robotic device without training or to additional sensorimotor robotic training ( about 4 h/week ) for 4 weeks . Robot training consisted of peripheral manipulation of the shoulder and elbow of the impaired limb , correlated with visual stimuli . Results : At hospital discharge , impairment and disability had declined in all patients , but the group with robot training showed higher gains on motor impairment and functional recovery , which were maintained at the 3-month follow-up . No adverse events result ed from robot-assisted therapy . Conclusions : According to our results , NeReBot therapy may efficaciously complement st and ard post-stroke multidisciplinary rehabilitation and offer novel therapeutic strategies for neurological rehabilitation OBJECTIVE to compare the effects of two different exercise programmes after hip fracture . DESIGN assessor-blinded r and omised controlled trial . SETTING hospital rehabilitation units , with continued intervention at home . SUBJECTS 160 people with surgical fixation for hip fracture transferred to inpatient rehabilitation . METHOD in addition to other rehabilitation strategies , the intervention group received a higher dose ( 60 min/day ) exercise programme conducted whilst st and ing and the control group received a lower dose exercise programme ( 30 min/day ) primarily conducted whilst seated/supine . The primary outcome measures were knee extensor muscle strength in the fractured leg and walking speed , measured at 4 and 16 weeks . RESULTS 150 participants ( 94 % of those recruited ) completed the trial . There were no differences between the groups for the two primary outcome measures . Post hoc analyses revealed increased walking speed among those in the higher dose , weight-bearing exercise group with cognitive impairment at 4 and 16 weeks . CONCLUSIONS there was no benefit ( or harm ) due to the higher dose , weight-bearing exercise programme with respect to the primary outcome measures . However , people with hip fracture and cognitive impairment gained greater benefit from the higher dose programme than from the lower dose programme The article by McKeough and colleagues in this issue of Chronic Respiratory Disease is the first study to compare different modes of upper extremity training in individuals with chronic obstructive pulmonary disease ( COPD ) . Limitations during exercise and daily activity in individuals with COPD are not limited to lower extremity activities such as walking or stair climbing ; most of the patients experience difficulty during activities that involve their arms due to the sensation of dyspnea and /or arm fatigue . Upper extremity training for patients with COPD is an important component of pulmonary rehabilitation ( PR ) , result ing in improvements in arm exercise capacity , arm function and muscle strength . However , there is limited evidence on what type of training should be performed . The study by McKeough and colleagues adds to the growing body of evidence in the area of upper extremity training in COPD and provides support for the inclusion of arm endurance and strength training as a part of PR . The study is a r and omized controlled trial ( RCT ) that aim ed to compare the effects of arm endurance training ; arm strength training , a combination of arm endurance and strength training ; and no arm training ( control group ) on endurance arm exercise capacity , functional arm exercise capacity and health-related quality of life ( HRQL ) in individuals with mild-tovery severe COPD . The authors found a significant improvement in arm endurance time ( arm endurance capacity ) between the endurance group and control group . There were nonsignificant trends in arm endurance time favoring the strength training and combined groups compared with the control group . In terms of symptoms , the authors demonstrated that the combined group had a significantly greater reduction in dyspnea and rate of perceived exertion at the end of the functional arm exercise test compared with the control and with each of the intervention groups . When the combined group was compared with the other two intervention groups , the improvement in HRQL ( measured using the St George ’s Respiratory Question naire ) exceeded the minimum clinical ly important difference of 4 units , although it did not reach statistical significance . Until the beginning of the century , several RCTs had been conducted to examine the effects of upper extremity training in individuals with COPD . However , there were considerable variations in the exercise protocol s rendering it impossible to determine the optimal training regimen for these patients . Moreover , the impact of upper extremity training on other clinical outcomes besides arm exercise capacity was unclear as shown consistently by four systematic review s. More recently , four RCTs examining the effects of arm exercise training in individuals with COPD have been published . Holl and and colleagues compared the effects of unsupported upper limb endurance training with lower extremity training alone . The authors found that unsupported upper limb endurance training improved upper limb exercise capacity but had no additional effects on the symptoms or HRQL compared with lower extremity training alone . Costi and colleagues examined the effects of upper extremity resistance training in patients with COPD compared with st and ard PR . The authors demonstrated improvement in arm functional exercise capacity ( measured using the 6-minute pegboard and ring test ) and in performance during activities of daily living ( ADL ) measured by an ADL field test . In addition , the authors found a decrease in arm fatigue at the end of the ADL test in the intervention group . BACKGROUND People with cognitive impairment and dementia have a poor outcome after a hip fracture surgery , about 30 - 50 % of all those who sustain a hip fracture have dementia . Therefore the aim was to investigate whether a multidisciplinary postoperative intervention program could reduce postoperative complications and improve functional recovery among people with dementia . METHODS A r and omized controlled trial with subgroup analyses among patients with dementia . Sixty-four patients with femoral neck fracture , aged ≥70 years at Umeå University Hospital , Sweden . The intervention consisted of staff education , individualized care planning and rehabilitation , active prevention , detection and treatment of postoperative complications , especially delirium . The staff worked in teams to apply comprehensive geriatric assessment , management and rehabilitation , including a follow-up at 4 months postoperatively . The control group followed conventional postoperative routines . RESULTS There were fewer postoperative complications in the intervention group such as urinary tract infections , p=0.001 ; nutritional problems , p=0.025 ; postoperative delirium , p=0.002 ; falls , p=0.006 . At 4 months a larger proportion in the intervention group had regained their previous independent indoor walking ability performance , p=0.005 . At 12 months a larger proportion in the intervention group had regained the activities of daily living ( ADL ) performance level they had before the fracture , p=0.027 . CONCLUSION This study demonstrates that patients with dementia who suffer a hip fracture can benefit from multidisciplinary geriatric assessment and rehabilitation and should not be excluded from rehabilitation programs Background and Purpose — Botulinum toxin is increasingly used to treat upper limb spasticity due to stroke , but its impact on arm function is unclear . We evaluated botulinum toxin for upper limb spasticity and function poststroke . Methods — Three hundred thirty-three patients with stroke with upper limb spasticity and reduced arm function participated in a multicenter r and omized controlled trial . The intervention group received botulinum toxin type A injection(s ) plus a 4-week therapy program . The control group received the therapy program alone . Repeat injection(s ) and therapy were available at 3 , 6 , and 9 months . The primary outcome was upper limb function at 1 month ( Action Research Arm Test ) . Secondary outcomes included measures of impairment , activity limitation , and pain at 1 , 3 , and 12 months . Outcome assessment s were blinded and analysis was by intention to treat . Results — There was no significant difference in achievement of improved arm function ( Action Research Arm Test ) at 1 month ( intervention group : 42 of 167 [ 25.1 % ] , control group 30 of 154 [ 19.5 % ] ; P=0.232 ) . Significant differences in favor of the intervention group were seen in muscle tone at 1 month ; upper limb strength at 3 months ; basic arm functional tasks ( h and hygiene , facilitation of dressing ) at 1 , 3 , and 12 months ; and pain at 12 months . Conclusions — Botulinum toxin type A is unlikely to be useful for improving active upper limb function ( eg , reaching and grasping ) in the majority of patients with spasticity after stroke , but it may improve basic upper limb tasks ( h and hygiene , facilitation of dressing ) and pain
There was preliminary evidence from one trial that exercise to the non-injured arm during immobilisation might lead to short-term benefits on increasing grip strength and range of movement following distal radius fracture .
There is emerging evidence that current prescribed exercise regimens may not be effective in reducing impairments and improving activity following an upper limb fracture .
Starting exercise early combined with a shorter immobilisation period is more effective than starting exercise after a longer immobilisation period .
QUESTION What is the effect of exercise on increasing participation and activity levels and reducing impairment in the rehabilitation of people with upper limb fractures ?
Bruder AM , Shields N , Dodd KJ , Taylor NF ( 2017 ) Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation : a systematic review .