A randomized trial on the efficacy of intensive rehabilitation in the acute phase of ischemic stroke

Background and Purpose-The purpose of this study was to determine the effects of augmented exercise therapy on gait, gait-related activities, and (basic and extended) activities of daily living within the first 6 months poststroke. Methods-A systematic literature search in electronic databases from 1990 until October 2010 was performed. Randomized controlled trials were included in which the experimental group spent augmented time in lower-limb exercise therapy compared with the control group. Outcomes were gait, gait-related activities, and (extended) activities of daily living.Results from individual studies were pooled by calculating the summary effect sizes. Subgroup analyses were applied for a treatment contrast of Ն16 hours, timing poststroke, type of control intervention, and methodological quality. Results-Fourteen (Nϭ725) of 4966 identified studies were included. Pooling resulted in small to moderate significant summary effect sizes in favor of augmented exercise therapy for walking ability, comfortable and maximum walking speed, and extended activities of daily living. No significant effects were found for basic activities of daily living. Subgroup analysis did not show a significant effect modification. Conclusions-Dose-response trials in stroke rehabilitation are heterogeneous. The present meta-analysis suggests that increased time spent on exercise of gait and gait-related activities in the first 6 months poststroke results in significant small to moderate effects in terms of walking ability, walking speed, and extended activities of daily living. High-quality dose-response exercise therapy trials are needed with identical treatment goals but incremental levels of intensity. (Stroke. 2011;42:3311-3315.)Key Words: dose-response Ⅲ exercise therapy Ⅲ intensity Ⅲ meta-analysis Ⅲ stroke S troke rehabilitation is characterized by early initiated, intensive, and ongoing training, in which task and context specificity play an important role. 1,2 There is indirect evidence that complex rehabilitation interventions may prevent inactivity-related complications and enhance functional recovery after stroke. [3][4][5][6][7] However, the underlying mechanisms that drive these benefits are still poorly understood. 5 To optimize rehabilitation services for patients with stroke, a better understanding of the dose-response relationship between exercise therapy and functional outcome is needed. 1,2 A number of systematic reviews have demonstrated that augmented task-specific training defined as either additional time spent in exercise therapy 1,8 or increased number of repetitions 8,9 enhance outcome of gait-related activities, activities of daily living (ADL), and health-related quality of life. 10 French and colleagues' review showed that repetitive task-oriented training resulted in modest improvements of lower-limb function but not of upper-limb function. 9 Another meta-analysis suggested that augmented practice of at least 16 hours in the first 6 months poststroke was needed to gain a mean improvement in ADL o...

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“…18,21,22,25,26 A nonsignificant homogeneous SES was found (SMD 0.11 SDU [fixed]; 95% CI, Ϫ0.12 to 0.34; Pϭ0.360; I 2 ϭ23%).…”

Section: Activities Of Daily Livingmentioning

confidence: 99%

Effects of Augmented Exercise Therapy on Outcome of Gait and Gait-Related Activities in the First 6 Months After Stroke

Veerbeek

Koolstra

Ket

et al. 2011

Stroke

158

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“…Although one study showed no effect of intensive rehabilitative treatment (2 h/day vs. 45 min/day) in patients with acute hemispherical ischemic stroke causing severe disabilities, 18) several studies have reported that the intensity of acute exercise therapy for patients with physical impairment at a moderate or higher level has a favorable effect on physical function recovery. 19,20) Additionally, the total amount of time provided by occupational therapists was found to contribute significantly to gains in the FIM score during hospitalization.…”

Section: Discussionmentioning

confidence: 99%

Real-world Effectiveness of Speech Therapy Time on Cognitive Recovery in Older Patients with Acute Stroke

Sakai

Momosaki

2016

PRM

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Objective: The purpose of this research was to investigate the real-world effectiveness of speech therapy time on cognitive recovery in older patients with acute stroke. Methods: The participants of this retrospective cohort study were hospitalized patients with acute stroke registered in the Japan Rehabilitation Database between December 2005 and September 2014. The patients were divided into two groups according to the amount of time they spent undergoing speech therapy, i.e., a high-intensity speech therapy group and a control group. Multivariate linear regression analysis was performed to assess the association between cognitive Functional Independence Measure efficiency and high-intensity speech therapy. Results: Of the 3341 eligible stroke patients (mean age: 77 years) extracted from the database, 53% received high-intensity speech therapy. Patients in the high-intensity speech therapy group had significantly higher cognitive Functional Independence Measure efficiency scores than those in the control group (mean, 0.17 vs. 0.10, respectively; P < 0.001). Multivariate regression analysis showed that cognitive Functional Independence Measure efficiency was significantly and positively correlated with high-intensity speech therapy (coefficient, 0.03; 95% confidence interval, 0.004-0.056; P = 0.026). Conclusions: These data suggest that a large amount of speech therapy time in older patients with acute stroke is a significant predictor of good cognitive recovery. Increased amounts of speech therapy for such patients may lead to better cognitive recovery after stroke.

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“…Whether the intensity of PT should be adapted to the severity of stroke deserves further investigation because other studies also observed negative results among patients with severe 22 but also with mild or moderate stroke, with NIHSS score ranging from 4 to 12. 11,21,23,27 Then the question addressed by this trial is the usefulness of intensive active PT in the acute stage after stroke. To stimulate recovery by means of neural plasticity, intensity of rehabilitation was found effective, but most of the studies were conducted with patients at the subacute stage, from 2 weeks to 3 months.…”

Section: Discussionmentioning

confidence: 99%

“…The study by Di Lauro et al found no difference between relatively intensive exercises, 2 hours/d of treatment, including 45 minutes of active work, versus 45 minutes of ordinary rehabilitative treatment. 21 In the EXPLICIT randomized controlled trial (Explaining Plasticity After Stroke), patients with severe stroke received 2 sessions of 30 minutes of an electromyography-triggered neuromuscular stimulation of the finger extensors, without positive effect. 22 Finally, our results agree with those from previous studies, which allows for drawing recommendations for rehabilitation early after stroke.…”

Section: Discussionmentioning

confidence: 99%

“…A positive impact on walking was observed, but intensive training consisted of only 20 minutes/d. 20 No beneficial effect of intensive training was observed in another study, 21 or the benefit was limited to patients with mild stroke. 22 The VECTORS trial (Very Early ConstraintInduced Movement During Stroke Rehabilitation) showed a negative effect of high-intensity constraint-induced movement therapy (90% of walking hours) and rehabilitation (3 hours/d).…”

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confidence: 97%

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AMOBES (Active Mobility Very Early After Stroke)

Yelnik

Quintaine

Andriantsifanetra

et al. 2017

Stroke

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In the early stage after stroke, within the first 2 weeks, physical therapy (PT) has 2 main goals: prevent immobilityrelated events and stimulate motor control recovery. However, the amount of PT to provide and the time after stroke for provision remain unclear.The organization of care in multidisciplinary stroke units has reduced the risk of death and dependency after stroke, with early mobilization and rehabilitation having an important role.1-3 Very early mobilization (VEM) was defined by the AVERT group (A Very Early Rehabilitation Trial): within the first 24 hours, focusing on out-of-bed activity (sitting, standing, walking), provided at least 3× more than usual care, by physical therapists or nurses. VEM has been found safe and feasible, 4 with a significant positive effect on recovery of walking 50 m unassisted, good functional prognosis on Barthel index at 3 months, 5 and for the frequency of severe complications. 6 Hemorrhagic stroke patients showed a better level of function (walking >15.24 m). 7 The recent European recommendations 8 and those from the American Stroke Association 9 promote VEM, although how early and how much a patient should be mobilized remains controversial. Some negative impact of early (<24 hours) versus delayed (<48 hours) physical rehabilitation has been reported, with increased risk of death. 10Background and Purpose-Intensive physical therapy (PT) facilitates motor recovery when provided during a subacute stage after stroke. The efficiency of very early intensive PT has been less investigated. We aimed to investigate whether intensive PT conducted within the first 2 weeks could aid recovery of motor control. Methods-This multicentre randomized controlled trial compared soft PT (20-min/d apart from respiratory needs) and intensive PT (idem+45 minutes of intensive exercises/day) initiated within the first 72 hours after a first hemispheric stroke. The primary outcome was change in motor control between day (D) 90 and D0 assessed by the Fugl-Meyer score. Main secondary outcomes were number of days to walking 10 m unassisted, balance, autonomy, quality of life, and unexpected medical events. All analyses were by intent to treat. Results-We could analyze data for 103 of the 104 included patients (51 control and 52 experimental group; 64 males; median age overall 67 [interquartile range 59-77], 67 right hemispheric lesions, 80 ischemic lesions, National Institutes of Health Stroke Scale score ≥8 for 82%). Fugl-Meyer score increased over time (P<0.0001), with no significant effect of treatment (P=0.29) or interaction between treatment and time (P=0.40). The median change in score between D90 and D0 was 27.5 (12-40) and 22.0 (12-56) for control and experimental groups (P=0.69). Similar results were found for the secondary criteria. Conclusions-Very early after stroke, intensive exercises may not be efficient in improving motor control. This conclusion may apply to mainly severe stroke. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01520636.

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A randomized trial on the efficacy of intensive rehabilitation in the acute phase of ischemic stroke

Cited by 43 publications

References 16 publications

Effects of Augmented Exercise Therapy on Outcome of Gait and Gait-Related Activities in the First 6 Months After Stroke

Effects of Augmented Exercise Therapy on Outcome of Gait and Gait-Related Activities in the First 6 Months After Stroke

Real-world Effectiveness of Speech Therapy Time on Cognitive Recovery in Older Patients with Acute Stroke

AMOBES (Active Mobility Very Early After Stroke)

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