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NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery
NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery

4. Lower Extremity, Balance, Mobility and Aerobic Training

Recommendations and/or Clinical Considerations
4.0 General Considerations
  1. Patients should participate in training that is meaningful, engaging, progressively adaptive, intensive, task-specific and goal-oriented, in an effort to improve transfer skills and mobility [Strong recommendation; High quality of evidence].
4.1 Lower Extremity Function and Gait
  1. Task-specific and goal-oriented training that is repetitive and progressively adapted should be delivered to improve performance of selected mobility tasks such as sit to stand, walking distance and walking speed [Strong recommendation; High quality of evidence].
    1. Both group and individual task-specific training are effective and may be considered [Strong recommendation; High quality of evidence].
  2. Resistance training should be considered for individuals with mild to moderate impairment in the lower extremity to improve strength and motor function; however, its impact on functional mobility is limited [Strong recommendation; High quality of evidence]. 
  3. Treadmill-based gait training (with or without body weight support) may be used to enhance walking speed, and distance walked as an adjunct to over-ground training or when over-ground training is not available or appropriate. [Strong recommendation; High quality of evidence]. 
  4. Electromechanical (robotic) assisted gait training devices are not recommended over conventional gait training [Strong recommendation; High quality of evidence]. 
  5. Rhythmic auditory stimulation (RAS) should be used to improve gait (i.e., walking speed, cadence, stride length) and function [Strong recommendation; High quality of evidence].
  6. Functional electrical stimulation (FES) should be used to improve balance, gait speed and mobility in selected individuals with stroke [Strong recommendation, High quality of evidence].
  7. Ankle-foot orthoses should be used with selected individuals with foot drop following proper assessment and with follow-up to verify their effectiveness to improve gait speed and balance [Strong recommendation; High quality of evidence]. 
  8. Aquatic exercise is recommended to improve walking speed and mobility [Strong recommendation; High quality of evidence].
  9. Non-immersive virtual reality training may be considered to improve lower extremity function, balance and gait (i.e., walking speed, cadence, stride length) as an adjunct to conventional gait training [Strong recommendation; Moderate quality of evidence].
  10. Biofeedback, in the form of visual and/or auditory signals, may be used to improve lower extremity function [Strong recommendation; Moderate quality of evidence]. 
  11. Mental imagery practice may be considered as an adjunct to gait training to improve gait speed [Strong recommendation; Low quality of evidence]. 

Section 4.1 Clinical Considerations

  1. The need for gait aids, wheelchairs, and other assistive devices should be evaluated on an individual basis.
    1. Once equipment has been provided, individuals with stroke should be reassessed, as appropriate, to determine progress, if changes or adjustments are required, and, if and when the equipment is no longer needed.
4.2 Balance
  1. The following therapies should be considered to improve balance following stroke (in addition to recommendations 4.1 ix and vi):
    1. Trunk training/seated balance training [Strong recommendation; High quality of evidence].
    2. Aquatic balance training [Strong recommendation; High quality of evidence]. 
    3. Tai Chi [Strong recommendation; High quality of evidence].
    4. Balance training combined with visual feedback or motor imagery training may be considered as an adjunct therapy [Strong recommendation; Moderate quality of evidence].
    5. The use of unstable surfaces and balance boards [Strong recommendation; Moderate quality of evidence]
    6. Whole-body vibration training is recommended as an adjunct therapy [Conditional recommendation; High quality of evidence]. 
  2. Force platform biofeedback is not recommended over conventional balance training [Strong recommendation; High quality of evidence].

Section 4.2 Clinical Considerations

  1. Therapists should consider both anticipatory and reactive balance control within their assessment and treatment.
4.3 Sit-to-Stand Function
  1. Sit-to-stand practice should be considered to improve sit to stand capacity [Strong recommendation; Moderate quality of evidence].
4.4 Aerobic Training

Refer to AEROBICS guidelines for additional information107

  1. Once medically stable, individuals with stroke should be considered for their ability to participate in aerobic exercise training [Strong recommendation; Moderate quality of evidence].
  2. Pre-participation evaluation should include assessment of physical activity behaviours and exercise history and a medical history and physical examination by appropriately qualified healthcare professionals with expertise in aerobic training to identify factors that require special consideration or constitute a contraindication to aerobic exercise [Strong recommendation; Moderate quality of evidence].
  3. If the plan is to conduct aerobic training at light intensity (e.g., <40% of predicted heart rate reserve), a submaximal exercise test may be considered [Strong recommendation; Moderate quality of evidence].
  4. Screening aerobic exercise tests should be conducted with monitoring of clinical signs and symptoms, heart rate, blood pressure, and rating of perceived exertion [Strong recommendation; Moderate quality of evidence]. 
    1. During a symptom-limited exercise stress test, an electrocardiogram should also be used to monitor electrocardiography [Strong recommendation; Moderate quality of evidence].
  5. Individually tailored aerobic training involving large muscle groups should be incorporated into a comprehensive stroke rehabilitation program to enhance cardiovascular endurance, balance and walking [Strong recommendation; High quality of evidence].
    1. To achieve a training effect, patients should participate in aerobic exercise for a minimum of 8 weeks [Strong recommendation; High quality of evidence], at least 3 times weekly progressing as tolerated from 5 to 20 minutes or more per session, exclusive of warm-up and cool-down [Strong recommendation; Moderate quality of evidence]. 
    2. Clinical signs and symptoms, heart rate, blood pressure, and rating of perceived exertion and other pertinent medical factors should be monitored during training to ensure safety and attainment of target exercise intensity [Strong recommendation; Moderate quality of evidence].   
  6. To ensure long-term maintenance of health benefits, a planned transition from structured aerobic exercise to more self-directed physical activity at home or in the community should be implemented [Strong recommendation; Moderate quality of evidence].
    1. Strategies to address specific barriers to physical activity related to individuals with stroke, healthcare providers, family, and/or the environment should be employed [Strong recommendation; Moderate quality of evidence].
Rationale +-

Mobility and balance impairments are highly prevalent post-stroke, particularly among individuals with more severe strokes, and affect a person’s safety, ability to perform daily activities and maintain independence. These issues often result from a combination of muscle weakness, reduced coordination, and sensory deficits, which can make movements such as standing and walking difficult. Loss of balance increases the risk of falls, further complicating recovery and rehabilitation efforts. Effective rehabilitation strategies, including physical therapy and balance training, are essential to help individuals regain their mobility, enhance their stability, and improve their overall quality of life after a stroke.

Individuals with stroke have highlighted the importance of repetition, progression and variation in stroke rehabilitation programs regarding gait, mobility and balance. Opportunities to practice skills in a variety of environments that mimic real life situations is also deemed helpful. Individuals with stroke emphasize the importance of the involvement of their family members and caregivers when receiving education and training regarding gait, mobility, and aerobic exercises. This includes how to safely and appropriately engage in aerobic exercise at home, as well as education and practice for safe and appropriate use of assistive devices.

Performance Measures +-

System Indicators

  1. Access to stroke rehabilitation services 7 days per week for inpatient care.
  2. Proportion of individuals within a stroke region who access an inpatient and community-based stroke rehabilitation as part of their episode of care for a stroke event.

Process Indicators

  1. Median length of time from stroke admission in an acute care hospital to assessment of rehabilitation potential by a rehabilitation healthcare professional.
  2. Median length of time spent in active rehabilitation on a stroke rehabilitation unit during inpatient rehabilitation.
  3. Median hours per day (minimum of three) of direct task-specific therapy provided by the interdisciplinary stroke team.
  4. Median days per week (minimum of five) of direct task specific therapy provided by the interdisciplinary stroke team.

Patient-Oriented Indicators 

  1. Extent of change (improvement) in functional status on the 6-Minute Walk Test from admission to an inpatient rehabilitation program to discharge. 
  2. Change (improvement) in functional status scores (e.g., FIM® Instrument sub score locomotion) from admission to an inpatient rehabilitation program to discharge.
  3. Extent of change (improvement) in functional status score (e.g., CMSA lower limb sub scale) from admission to an inpatient rehabilitation program to discharge. 
  4. Extent of change in functional status scores using a standardized assessment tool (e.g., FIM® Instrument) from admission to an inpatient rehabilitation program to discharge (average and median).
  5. Extent of change in lower limb functional status using a standardized assessment tool (e.g., Chedoke-McMaster Stroke Assessment sub scale) from admission to an inpatient rehabilitation program to discharge.
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices team or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Health Care Provider Information

Resources for Individuals with Stroke, Families and Caregivers 

Summary of the Evidence +-

Evidence Table and Reference List 4

Lower Extremity Gait Training

Task Oriented Training (Task-Specific Training
Task oriented training (also called task-specific training) involves active practice of task-specific motor activities. Repeated motor practice has been shown to improve walking speed and functional ambulation.

A Cochrane review by English et al. 109 pooled findings from 17 RCTs that compared circuit class training, provided for a minimum of once-weekly sessions for a minimum of 4 weeks, with no therapy, sham therapy, or another therapy modality. Only studies that reported interventions with a focus on repetitive practice of functional tasks arranged in a circuit, with the aim of improving mobility, were included.  Pooling the results from 10 trials, compared with any other intervention, circuit class training was associated with a significantly greater increase in distanced walked (m) in the 6-minute walk test (6MWT) (MD=60.86, 95% CI 44.55 to 77), a distance which exceeded the minimal clinically important difference of 34.4 metres. The mean gait speed in the intervention groups was 0.15 metres/ second faster (95% CI 0.10 to 0.19 m/s) compared with the control group. Other outcomes with scores significantly higher in the intervention group included Timed-up-and Go (TUG) test, Stroke Impact Scale, Functional Ambulation Classification and the Rivermead Mobility Index. In another Cochrane review, French et al. 14 examined task-specific training on upper and lower extremity functions compared with usual care, an alternative intervention, or no care. Lower extremity repetitive task-oriented training interventions were examined in 17 trials. Two trials focused on sit-to-stand practice, 6 trials focused on walking practice, while 4 trials investigated interventions that focused specifically on sitting balance trunk control, and balance. Repetitive task training was associated with significantly greater improvements in walking distance (MD= 34.80 metres, 95% CI 18.19 to 51.41 metres; 9 studies) and functional ambulation (SMD= 0.35, 95% CI 0.04 to 0.66; 8 studies), sit-to-stand post treatment (SMD=0.35, 95% CI 0.13 to 0.56, 7 studies) and standing balance or reach (SMD= 0.24, 95% CI 0.07 to 0.42; 9 studies).

Resistance Training
Many individuals experience muscle weakness as a consequence of stroke. Strength training may help to improve measures of gait and balance. Flansbjer et al. 110, 111 randomized 24 persons living in the community a minimum of 6 months post stroke to a training group that participated in supervised progressive resistance training of the knee muscles twice weekly for 10 weeks, or to a control group in which participants continued their usual daily activities. The authors found that on the paretic side, the mean dynamic knee muscle strength extension and flexion in the intervention group had improved significantly more at the end of treatment and was maintained at 4-year follow-up compared to the control group. However, there were no significant differences between groups in mean improvement on the TUG test, gait speed or distance traveled on the 6MWT at four years. Cooke et al. 112 randomized participants with subacute stroke (mean 1 month) to one of three treatment groups for a duration of 6 weeks: 1) conventional physiotherapy (CPT) + Functional Strength training (FST); 2) extra intensity training (CPT + CPT); or 3) CPT alone. Following the intervention both experimental groups showed improvement in walking speeds over the CPT alone group, but this reached significance in the CPT + CPT group. The CPT + CPT group also showed significant improvement in the number of participants with a walking speed over 0.8m/s compared to the CPT group. No significant differences were noted between-groups for torque about the knee, symmetry step length, symmetry step time, the Rivermead score, or on the EuroQoL. At the 12-week follow-up no significant differences were identified between groups.

Treadmill Training with and without Body Weight Support
In a Cochrane review, Mehrholz et al. 113 included the result of 56 trials (n=3,105) and concluded that patients with stroke who received treadmill training (with or without body weight support) in combination with physiotherapy had significantly improved gait velocity (MD=0.06 m/s, 95% CI 0.03 to 0.09) and greater walking endurance (MD=14.19 metres, 95% CI 2.92 to 25.46), when assessed at the end of treatment. Among studies evaluating treadmill training with body weight support, patients were no more likely to achieve independent walking than patients receiving gait training without these devices (risk difference= -0.00, 95% CI -0.02 to 0.02), nor was gait velocity or walking endurance increased significantly at the end of scheduled follow-up (MD=0.03 m/s, 95% CI -0.05 to 0.10 and MD= 21.64 m, 95% CI -4.70 to 47.98). In the MOBILISE trial, 114, 115 126 patients were randomized to an experimental or a control group within 28 days of stroke and received treatment until they achieved independent walking or for as long as they remained in hospital. Participants in both groups received 30 minutes of walking practice 5 days/week. Additional lower extremity therapy was provided for an additional 30 minutes/day. Participants in the experimental group undertook up to 30 minutes per day of treadmill walking with sufficient body weight support such that initially, the knee was within 15 degrees of extension in mid stance. The control group received up to 30 minutes of over-ground walking training, with the use of aids, if required. Although there were no differences in the proportion of independent ambulators between groups at one, two or 6 months, participants in the experimental group achieved independence in ambulation a median of 14 days sooner. In the Locomotor Experience Applied Post Stroke (LEAPS) trial, Nadeau et al. 116 randomized 408 patients with residual paresis who were able to walk 10 feet with no more than one-person assistance and within 45 days of stroke onset to one of 3 programs: 1) Locomotor training program (LTP), 2) Home exercise program (HEP), or 3) Usual Care (UC). Both LTP and HEP programs were of similar duration and intensity (90-minute sessions, 3 times/week) for 12-16 weeks, for a total of 30 to 36 exercise sessions. At 6 months, 50.4% of LTP, 49.2% of HEP, and 32.2% of UC patients had improved to a higher functional walking level with no significant differences between the LTP and HEP groups.

Electromechanical/Robot-Assisted Gait Training Devices
In an updated Cochrane review, Mehrholz et al. 117 included 62 trials including 2,440 participants with difficulty walking following a stroke and examined the effectiveness of electromechanical and robot-assisted gait training for improving walking after stroke. Treatments included electromechanical and robot-assisted gait training devices (with or without electrical stimulation) which are designed to assist stepping cycles by supporting body weight and automating the walking therapy process with the addition of physiotherapy compared with physiotherapy or routine care only. Electromechanical-assisted gait training in combination with physiotherapy increased the odds of participants becoming independent in walking at the end of treatment (Odds ratio [OR]=2.01, 95% CI 1.51 to 2.69; 38 trials; GRADE: high certainty); however, the benefit was lost at the end of follow-up, which averaged 22.3 weeks (OR=1.93, 95% CI 0.72 to 5.13; 6 trials; GRADE: low certainty). At the end of the intervention, walking speed was also significantly faster in the experimental group (MD=0.06 m/s, 95% CI 0.02 to 0.1; 42 trials: GRADE: low certainty), with the benefit lost at the end of follow-up, which averaged 19 weeks (MD=0.07 m/s, 95% CI - 0.03 to 0.17; 13 trials; GRADE: low certainty). At neither the end of the intervention, nor at follow-up (mean of 18 weeks), was walking capacity (distance walked in 6 minutes) significantly improved in the experimental group (MD=10.86 meters, 95% CI -5.72 to 27.44; 24 trials and MD=7.76 meters, 95% CI -21.47 to 36.99; 11 trials. GRADE: moderate). Molteni et al. 118 included 75 patients with first-ever stroke, with onset within the previous 35 days, and limited ambulation capacity in the Stroke Rehabilitation with Exoskeleton-assisted Gait. (EKSOGAIT) trial. In addition to conventional rehabilitation that all patients received for 120 minutes daily, 6 days a week, Patients were also randomized to an experimental group and received 15 sessions (60 minutes each, 5 days/week for 3 weeks) with the Ekso™ device (an exoskeleton) or the same amount of conventional gait training (control group). There was no significant difference in the primary outcome (6MWT) between groups at the end of the intervention. The mean distance walked from baseline to end of treatment increased from 48.60 meters to 139.24 m in the experimental group and from 44.29 meters to 149.43 in the control group.

Rhythmic Auditory Stimulation (RAS)
Rhythmic auditory cueing or stimulation, whereby walking is synchronized to a rhythmic auditory cue, may help to improve motor learning following a stroke. Ghai & Ghai 119 examined music-based auditory cueing in addition to conventional physical therapy, including the results from 38 trials (11 RCTs). RAS was associated with significantly improved  gait velocity (Hedges’ g=0.68, 95% CI 0.42 to 0.93; 25 trials included), increased stride length (Hedges’ g=0.50, 95% CI 0.26 to 0.73; 20 trials included), improved cadence (Hedges’ g=0.86, 95% CI 0.50 to 1.22; 23 trials included) and improvement in TUG  (g= -0.76, 95% CI -1.36 to −0.16; 6 trials included). Yoo & Kim 120 included the results of 8 RCTs (n=242) comparing intentional synchronization of target movement to externally generated rhythmic auditory cueing with traditional rehabilitative interventions or other controlled interventions in persons with hemiparesis following stroke. RAS was associated with large significant effect sizes for all lower extremity outcomes, including gait velocity (Hedges’ g=0.98, 95% CI 0.69 to 1.28), cadence (Hedges’s g=0.84, 95% CI 0.63 to 1.15) and stride length (Hedges’ g=0.76, 95% CI 0.47 to 1.05).

Virtual Reality (VR)
Zhang et al.121 included 87 RCTs including 3,540 participants with stroke with upper and lower disability, with varying chronicity of stroke. In this systematic review, trials compared VR rehabilitation interventions, with many trials using commercially available devices such as Xbox Kinect TM vs. conventional rehabilitation or placebo therapy. At the end of treatment, VR interventions were associated with significantly higher Fugl-Meyer Assessment-lower extremity (FMA-LE) scores (MD=3.01, 95% CI 1.91–4.11; 16 trials, n=732), Functional Ambulation Categories (FAC) scores (MD= 0.47, 95% CI = 0.14–0.79; 5 trials, n=260), and gait speed (MD=11.79 cm/sec, 95% CI 8.48–15.11; 9 trials, n=310), compared with conventional rehabilitation. A Cochrane review 33 included the results of 72 trials, which evaluated the effect of virtual reality and interactive video gaming. While most of the trials assessed upper intervention, a few assessed mobility outcomes. In these trials, virtual reality was not associated with significant improvements in gait speed, balance or TUG tests at the end of the intervention compared with conventional therapy. Iruthayarajah et al. 122 included the results of 22 RCTs specifically examining the use of virtual reality in the chronic stage of stroke to improve balance. Interventions included the Wii Fit balance board, and treadmill training and postural training combined with virtual reality applications. Combining the results of 12 trials, VR interventions were associated with a significantly greater improvement in Berg Balance Scale (BBS) scores (MD=2.94, 95%CI 1.82–4.06, p<0.001). Gibbons et al. 123 included the results of 22 trials (552 participants) evaluating the effects of VR interventions on lower extremity outcomes post stroke. Pooled analyses were possible for studies including patients in the chronic stage of stroke. In the VR group, functional balance was improved significantly more following treatment (SMD=0.42, 95% CI 0.11 to 0.73), but not at follow-up (SMD=0.38, 95% CI -0.73 to 1.50). Gait velocity, cadence, stride length and step length were also significantly improved immediately following the intervention in the VR group.

Mental Practice (MP)
Mental practice can help facilitate motor recovery by activating the same neural circuits that are involved in performing the action. Silva et al. 124 conducted a Cochrane review including 20 RCTs of 762 participants recovering from stroke. Trials compared motor imagery +/- action observation, physical activity, or functional gait training. In most trials, the participants were asked to imagine isolated movements related to gait or to imagine rigorous sports movements. Each session was 30-60 minutes with a total dose of 100 to 1,200 minutes over 2-8 weeks. The control condition was physical therapy in most trials (total dose was 12 to 240 minutes). Mental practice was associated with an increase in gait speed compared with usual care (SMD=0.44, 95% CI 0.06 to 0.81, 6 trials, n=191; GRADE: very low certainty) but not with motor function assessed using the FMA-LE or functional mobility assessed with Rivermead Mobility Index or TUG.

Functional Electrical Stimulation (FES)
FES can be used to improve gait quality in selected patients who are highly motivated and able to walk independently or with minimal assistance A systematic review including the results of 14 trials examined the use of FES applied to the paretic peroneal nerve +/- cointerventions vs. conventional treatment. 125 Peroneal nerve devices were used in 12 trials, with conventional FES devices used in two trials. The stimulation sessions ranged from 20-60 minutes, 1-7x/week, for one day to 30 weeks. FES + supervised exercises was associated with a significant improvement on the 10 Meter Walk Test (10MWT) compared with supervised exercise alone (SMD=0.51, 95% CI 0.16 to 0.86; 5 studies, n= 133) and in TUG (MD = -3.19 sec, 95% CI -5.76 to -0.62; 5 studies, n=780) compared with conventional therapy. A systematic review by Howlett et al.126 included 18 trials of FES for improving upper or lower extremity activity compared to placebo, no treatment or training alone. FES was associated with significantly faster gait speed compared with training alone (MD= 0.08 m/s, 95% CI 0.02 to 0.15; results from 8 trials, 203 participants). However, an older Cochrane review 127 including the results from 24 RCTs, of which 12 evaluated interventions and outcomes associated with mobility. The results suggested that active FES was not associated with significant increases in gait speed (SMD= -0.02, 95% CI -0.30 to 0.26) or stride length (SMD=0.36, 95% CI -0.93 to 1.63).

Biofeedback
Stanton et al.128 included the results of 18 trials evaluating biofeedback. Active interventions included force platforms, EMG biofeedback, audio and visual feedback, provided for an average of 5 weeks. Overall, biofeedback improved lower extremity activities compared with usual therapy (SMD= 0.50, 95% CI 0.30 to 0.70).

Ankle-Foot Orthoses (AFO)
The use of ankle-foot orthoses is widespread. The results from several recent systematic reviews suggest that AFOs can be used to improve mobility and gait parameters. Their use has been associated with significant improvements in TUG, FAC, 6MWT and Motricity Index (MI), compared with no AFO use. 129 Choo & Chang 130 reported significant improvement in cadence, step length and stride length in a systematic review of 19 trials, including 434 participants in the subacute or chronic stage post stroke. An older Cochrane review conducted by Tyson & Kent 131 included the results from 13 RCTs. During a single testing session, participants performed significantly better on measures of balance (weight distribution: SMD=0.32, 95% CI -0.52 to -0.11, p=0.003) and mobility (gait speed: MD=0.06 m/s, 95% CI, 0.03 to 0.08, p<0.0001 and stride length: SMD= 0.28, 95% CI 0.05 to 0.51, p=0.02) while wearing an AFO compared with the control condition where an AFO was not worn. There was no significant treatment effects associated with the outcomes of postural sway and timed mobility tests. In 32 chronic stroke survivors who were randomized to wear or not wear an AFO for a period of three months, gait speed was significantly increased as was and Physiological Cost Index (beats/min) in patients who had worn the device.132

Aquatic Exercise
Aquatic exercise was associated with a significant improvement in gait speed, (SMD=−0.45; 95% CI-0.71 to −0.19) and mobility (SMD= −0.43, 95% CI -0.7 to - 0.17) compared with conventional therapy, in a systematic review including the results of 17 RCTs. 133 In another systematic review including the results from 11 RCTs, 134 hydrotherapy was associated with significant improvements in Forward Reach Test (MD= 1.78, 95% C, TUGT (MD=−1.41, 95% CI −2.44 to -0.42), and knee extensor torque (MD= 6.14, 95% CI 0.59-11.7).


Balance Training

Trunk Training
Trunk training exercises can be assed to standard physiotherapy to help improve balance. Thijs et al.45 conducted a Cochrane review including the results from 68 RCTs including 2,585 participants recovering from stroke across the recovery continuum. Trunk training interventions assessed included core-stability training (isometric strengthening of the trunk muscles, n=18 trials)  electrical stimulation that targeted ≥ 1 core trunk muscles (n=7 trials), selective-trunk training aimed at improving selective movements of the upper and lower part of the trunk (n=15 trials), sitting-reaching therapy (n=6 trials), 10° steady-tilted platform (n=2 trials) and weight-shift training (n=4 trials). The median duration of therapy was 4 weeks, providing a median of 600 minutes of total training. The intensity of training ranged from 30 minutes to 2,700 minutes (45 hours). Trials were classified as dose-dependent (n=44) or non-dose dependent (n=20), based on the amount of therapy provided in the control arms. Therapy provided in the control groups was diverse. Trunk training was associated with a significant improvement in standing balance (SMD=0.57, 95% CI 0.35 to 0.79; 11 trials included; GRADE: very low certainty); and walking ability (SMD=0.73, 95% CI 0.52 to 0.94; 11 trials included; GRADE: very low certainty), compared with non-dose-matched therapy. Compared with dose-matched therapy, trunk training was associated with a significant improvement in standing balance (SMD=1.00, 95% CI 0.86 to 1.15; 22 trials included; GRADE: very low certainty) and walking ability (SMD=0.69, 95% CI 0.51 to 0.87; 19 trials included; GRADE: low certainty). Bank et al.135 included the results of 11 RCTs in a systematic review that investigated physiotherapy plus additional therapy (targeted mainly at improving sitting and standing balance). Compared with conventional physiotherapy alone, additional trunk training exercises did not result in significant differences between groups on the Trunk Control test (MD=-1.53, 95%CI -9.37–6.32, p=0.70; 5 studies, n=263), but was associated with significantly higher Trunk Impairment Scale scores (MD=1.70, 0.62–2.78, p=0.007; 4 studies, n=106).

Force Platform with Feedback
A 2004 Cochrane review 136 included 7 RCTs of 246 participants with abnormal weight bearing in the standing position or impaired standing balance following stroke. Trials compared force platform balance training with visual or auditory feedback vs. conventional treatment or other balance training or placebo balance training. Treatment duration ranged from two to 8 weeks. Intensity and frequency of treatment ranged from 20-60 minutes/session and 2-5 days/week. Visual feedback force platform feedback was not associated with significant improvement in either of the primary outcomes, pooling the results from two to three trials (BBS: MD=-1.98, 95% CI -5.55 to 1.59; and TUG: MD=7.31, 95% CI -1.32 to 15.94). Another systematic review 137 included the results from 8 trials of 214 participants recovering from stroke in the subacute and chronic stages. Trials compared visual feedback balance training using commercially available force platforms devices vs. conventional balance training. Treatment duration was two to 8 weeks. In pooled analyses, visual feedback balance training was not associated with significant differences between groups for any of the balance outcomes of interest (postural sway, weight distribution, BBS and TUG).

Aquatic Exercises
The benefit of aquatic exercises or hydrotherapy compared with land-based training for improving measures of balance was assessed in three recent systematic reviews, each including 11, 15 and 17 RCTs. Sessions in all included trials were typically provided for 30 to 60 minutes, two to 5 times per week and lasted for two to 12 weeks. Significantly greater improvements in BBS scores were reported in pooled analyses in two reviews with mean between group differences at the end of treatment of 1.55 and 1.60 points. 134, 138 In the third review, 133, the standardized mean difference in balance scores was 0.72 (95% CI 0.50–0.94).

Tai-Chi
In three recent systematic reviews, improved balance was reported following a course of traditional Chinese exercises or Tai Chi +/- additional rehabilitation therapies, compared with rehabilitation therapies only. The duration of therapy ranged widely from two to 52 weeks. Tai Chi or traditional Chinese exercises were associated with significantly greater improvement in BBS scores with mean differences of 4.87 (95% CI 4.46–5.28), 139 7.67 ( 95% CI 3.44 -11.90), 140 and 2.07 (95% CI 1.52-2.62).141

Balance Training + Motor Imagery
When added to a program of traditional balance training, motor imagery has been shown to improve balance compared with balance training only. Zhao et al. 142 included the results of 23 RCTs including 1,109 participants with motor dysfunction of the lower extremity. In most trials, kinesthetic motor imagery was used, whereby patients perceive their proprioception with the first-person view performing the movement. Motor imagery + conventional rehabilitation was associated with significantly greater improvement in BBS scores, a secondary outcome (MD=6.29, 95% CI 2.82-9.79).

Whole Body Vibration
In two systematic reviews that compared whole-body vibration training (WBVT) + conventional rehabilitation vs. conventional rehabilitation only, the addition of WBVT was associated with significantly greater improvements in BBS scores with between group mean differences of 4.08 (95% CI 2.39-5.76) 143 and 4.23 (95% CI 2.21-6.26) 144 after four to 12 weeks of treatment.


Sit-to-Stand
A Cochrane review 145 included the results of 13 RCTs that examined repetitive sit-to-stand training, exercise training programs that included sit-to-stand training, sitting training and augmented feedback. Compared with usual care/ or no treatment, repetitive sit-to-stand was associated with increased odds of independence in sit-to-stand (OR=4.86, 95% CI 1.43–16.50), although the results from only one trial were included. Active intervention reduced the time needed for sit-to-stand (SMD=-0.34, 95% CI -0.62 to -0.06, n=7 trials), and improved lateral symmetry (SMD=0.85, 95%CI 0.38–1.33, n=5 trials), but did not reduce the risk of falling (OR=0.75, 95% CI 0.46 to 1.22, n=5 trials).

Aerobic Training
An updated Cochrane review 146 included the results from 75 RCTs trials of patients in both the acute and chronic stages of stroke. Interventions were classified as 1) cardiorespiratory training (circuit training, aquatic training, ergometry, and treadmill training, 2) resistance training (using weights, exercise machines, or elastic devices) and 3) mixed training interventions using various combinations of walking, treadmill training, and resistance training, which included combinations of cardiorespiratory and resistance training methods. The control conditions included usual care, no intervention, or a non-exercise intervention. At the end of the intervention, cardiorespiratory training was associated with significant increases in physical fitness, preferred walking speed and walking capacity, and reductions in disability. Increases in muscle strength, preferred walking speed, and improved walking capacity and balance were also associated with resistance training interventions. Both Sandberg et al. 147 and Hornby et al. 148 reported significantly greater improvements in the 6MWT in RCTs associated with aerobic training, compared with conventional rehabilitation in persons with acute and chronic stroke. Gait speed and fastest possible walking speed were also significantly higher in the aerobic training group. 148, 149 Globas et al. 150 reported significant improvements in measures of cardiovascular fitness, walking ability and performance in patients more than 6 months post stroke who had received a progressive graded, high-intensity aerobic treadmill exercise or aerobic cycling exercise, with lower extremity weights.

Pharmacotherapy & Functional Recovery
Selective serotonin reuptake inhibitors (SSRIs) have been investigated as a potential modulator of functional recovery post stroke, in patients both with and without mood disorders post-stroke. Unfortunately, there appears to be increasing evidence that SSRIs do not help to reduce disability or improve independence and may, in fact, be associated with harm. Mead et al. 53 included the results from three large RCTs in a patient-level meta-analysis, which recruited 5,907 patients with persisting focal neurological deficit following acute stroke. All participants were randomized to receive 20 mg fluoxetine daily or placebo for 6 months. Trials included were The Efficacy oF Fluoxetine-a randomisEd Controlled Trial in Stroke (EFFECTS 54), the Assessment oF FluoxetINe In sTroke recovery trial (AFFINITY, 55) and the Fluoxetine Or Control Under Supervision (FOCUS) trial. 56 At 6 months, the distribution of modified Rankin Scale (mRS) scores did not differ significantly between groups (common OR=0.96, 95% CI 0.87 to 1.05; GRADE: high quality). Neither was the distribution of scores significantly different between groups at 12 months (common OR=0.98, 95% CI 0.89 to 1.07). Fluoxetine was associated with a significantly increased frequency of seizures (2.64% vs. 1.8%, p=0.03), falls with injury (6.26% vs 4.51%, p=0∙03), and fractures (3.15% vs 1.39%, p=0.01). In a Cochrane review, Legg et al. 57 included 76 RCTs including 13,029 participants who had suffered a stroke within the previous 12 months. Trials compared a variety of SSRIs vs. placebo. In most trials, patients were recruited in the early stages of stroke. There was no significant difference between groups in measures of disability (SMD=0.0, 95% CI -0.5 to 0.5, 5 trials; GRADE: high), nor was there a better chance of being independent at the end of treatment (RR=0.98, 95% CI 0.93 to 1.03, 5 trials; GRADE: high). SSRIs were associated with significantly higher risks of seizures and bone fractures.


Sex & Gender Considerations

While women are more likely to survive strokes than men, they tend to experience greater disability. Potential reasons for this imbalance may include greater initial stroke severity, higher pre-stroke disability and older age at stroke onset. 58 Data are limited with respect to rehabilitation outcomes with respect to sex. MacDonald et al. 59 used administrative data sets including 20,143 patients and compared sex differences in discharge Functional Independence Measure (FIM) scores from inpatient rehabilitation units in Ontario over a 5-year period. While in unadjusted analysis, women had a lower mean FIM score (94.1 vs. 97.8, p < 0.001), after adjusting for baseline characteristics, the difference was no longer significant. There is some evidence that women are under-represented in stroke rehabilitation clinical trials. In a recent systematic review, 151 examining female recruitment in 1,285 randomized trials investigating lower-extremity rehabilitation interventions, the overall percentage of women included across all trials was 39.4%. The trials included participants across all stages of stroke chronicity, all rehabilitation settings, and intervention types (pharmacological, traditional and nontraditional rehabilitation therapies, and complementary interventions).

Stroke Resources
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