Effects of Augmented Exercise Therapy Time After Stroke

Abstract

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.

Investigating Measures of Intensity During a Structured Upper Limb Exercise Program in Stroke Rehabilitation: An Exploratory Study

“…This finding is reflective of a recent systematic review which also identified stroke survivors to be physically active for on average 60% of their physiotherapy sessions 12 . It is important to note that as the sessions in this study consisted solely of completing the GRASP exercises, and did not include other activities (e.g.…”

“…Time continues to remain the dominant measure of intensity both in research 7,12 and in clinical guidelines 13,14 . It is the measure used to synthesize data in meta-analyses 3,12,15 and is the standard by which clinicians and services are evaluated 16 .…”

“…It is the measure used to synthesize data in meta-analyses 3,12,15 and is the standard by which clinicians and services are evaluated 16 . However it has been recognised that time is a proxy measure for intensity and provides a rather crude estimate 17 .…”

“…Despite the strength of evidence supporting intensity, objectively quantifying intensity of therapy in stroke rehabilitation remains problematic. It is difficult to determine and increase intensity, without first having robust, feasible methods to be able to measure intensity during rehabilitation.Time continues to remain the dominant measure of intensity both in research 7,12 and in clinical guidelines 13,14 . It is the measure used to synthesize data in meta-analyses 3,12,15 and is the standard by which clinicians and services are evaluated 16 .…”

Hamstring tendon autograft better than bone–patellar tendon–bone autograft in ACL reconstruction—a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis

“…The classical funnel plot of the metaanalysis is therefore ordered by increment of the variable studied, for instance chronologically by date of publication as in the seminal report by Lau et al (1992), or by duration of exercise therapy as in the article by Kwakkel et al (2004). The interest of a cumulative meta-analysis ordered by date of publication, as indicated by the authors, is that it may show the time at which sufficient evidence of the superiority of one treatment over another has accumulated.…”