Background and Purpose-To present a systematic review of studies that addresses the effects of intensity of augmented exercise therapy time (AETT) on activities of daily living (ADL), walking, and dexterity in patients with stroke. Summary of Review-A database of articles published from 1966 to November 2003 was compiled from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE, and PiCarta using combinations of the following key words: stroke, cerebrovascular disorders, physical therapy, physiotherapy, occupational therapy, exercise therapy, rehabilitation, intensity, dose-response relationship, effectiveness, and randomized controlled trial. References presented in relevant publications were examined as well as abstracts in proceedings. Studies that satisfied the following selection criteria were included: (1) patients had a diagnosis of stroke; (2) effects of intensity of exercise training were investigated; and (3) design of the study was a randomized controlled trial (RCT). For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) expressed in standard deviation units (SDU) were calculated for ADL, walking speed, and dexterity using fixed and random effect models. Correlation coefficients were calculated between observed individual effect sizes on ADL of each study, additional time spent on exercise training, and methodological quality. Cumulative meta-analyses (random effects model) adjusted for the difference in treatment intensity in each study was used for the trials evaluating the effects of AETT provided. Twenty of the 31 candidate studies, involving 2686 stroke patients, were included in the synthesis. The methodological quality ranged from 2 to 10 out of the maximum score of 14 points. The meta-analysis resulted in a small but statistically significant SES with regard to ADL measured at the end of the intervention phase. Further analysis showed a significant homogeneous SES for 17 studies that investigated effects of increased exercise intensity within the first 6 months after stroke. No significant SES was observed for the 3 studies conducted in the chronic phase. Cumulative meta-analysis strongly suggests that at least a 16-hour difference in treatment time between experimental and control groups provided in the first 6 months after stroke is needed to obtain significant differences in ADL. A significant SES supporting a higher intensity was also observed for instrumental ADL and walking speed, whereas no significant SES was found for dexterity. Conclusion-The results of the present research synthesis support the hypothesis that augmented exercise therapy has a small but favorable effect on ADL, particularly if therapy input is augmented at least 16 hours within the first 6 months after stroke. This meta-analysis also suggests that clinically relevant treatment effects may be achieved on instrumental ADL and gait speed.
Physiotherapy is an established component of stroke rehabilitation but uncertainties remain about the most appropriate intensity of therapy input. We conducted a systematic review of the randomised trials of physiotherapy after stroke where qualitatively similar therapy regimens were provided at different levels of intensity. A heterogeneous group of seven randomised trials (597 patients) was identified. Dichotomous outcomes (death or the combined poor outcome of death or deterioration) were analysed by use of the odds ratio and 95% confidence interval. Patients subjected to more intensive physiotherapy input showed a non-significant reduction in case fatality (odds ratio 0.60; 95% CI 0.33-1.09) and a significant reduction (OR 0.54; 95% CI 0.34-0.85; p < 0.01) in the combined poor outcome of death or deterioration by the end of follow-up. Two statistical techniques were used to identify patterns within the continuous data. Firstly, impairment and disability scores were converted to a standardised measure of 0-100 and the weighted mean difference (WMD) between the scores in the intensive and conventional physiotherapy groups were then calculated. Modest improvements were observed in both the impairment (WMD+5; 95% CI-1-11) and disability scores (WMD+5; 95% CI 0-10) recorded at the initial review (median 3 months post-stroke), but not at the final review (median 1 year post-stroke). Secondly, Fisher's inverse chi-squared test was used to combine the p values from individual trials; this confirmed the above findings (p < 0.05 at initial review; p > 0.05 at final review). More intensive physiotherapy input was associated with a reduction in the combined poor outcome of death or deterioration and may enhance the rate of recovery. These observations warrant further investigation.
The Stroke Self-Efficacy Questionnaire could assist clinicians and researchers working in acute stroke care and rehabilitation to screen levels of confidence of stroke survivors in relation to functional performance and self-management. The Stroke Self-Efficacy Questionnaire could be used as part of battery of stroke outcome measures to provide a more comprehensive overview of factors influencing performance in the individuals recovering from a stroke.
There is preliminary evidence that the use of an individualized stroke self-management intervention is acceptable and can lead to a change in self-efficacy in this small sample.
An important finding of this study was that individuals all identified a number of specific factors which had supported or hindered their own recovery. There were a diversity of both internal/personal and external factors which may not be surprising, given the complexity of stroke, but all participants stressed the importance of both factors. The findings from this study are preliminary and relate only to this particular group of participants, as such they cannot be generalizable to the stroke population as a whole. However, the interaction between the two themes identified requires further exploration, especially in relation to therapy which could have both a positive and negative influence on personal control. There is a clear need to understand how professionals can, in the first place, take time to identify each individual's preferences and personal goals and secondly, make sure that these are fully addressed in a planned treatment programme. This will ensure that progress in individuals after stroke is supported by professionals with a more eclectic, individualized approach.
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