Stroke: How to Re-Train (The Successful Stroke Survivor Book 3)

The publisher's final edited version of this article is available at Expert Rev Neurother. See other articles in PMC that cite the published article. Abstract Stroke is a leading cause of long-term disability. Walking ability of people with stroke Stroke is a leading cause of long-term disability which results from brain cell damage due to either an interruption of the blood supply to the brain or hemorrhage into the brain tissue. Major determinants of ambulation function in stroke Understanding the impairments that primarily determine walking ability of individuals with stroke will help with the development of effective gait training strategies.

Open in a separate window. Training strategies to improving walking ability in people with stroke A systematic review of training strategies to improve walking ability in people with stroke was undertaken. Neurodevelopmental approaches to improve walking ability Traditional approaches to stroke recovery have a focus on neurofacilitation or neurodevelopmental techniques NDT to inhibit excessive tone, stimulate muscle activity if hypotonia is present and to facilitate normal movement patterns through hands-on techniques.

No group differences in gait speed. Intensive group had faster but not significant speed at 6 weeks post-stroke compared to other 2 groups. Functional training passive range of motion, progressive resistive exercises even in the presence of spasticity, early use of assistive device and bracing Gait speed: Strength training to improve walking ability Bobath [ 99 ] advocated that decreased muscle function was not due to weakness but to the opposition of spastic antagonists and that strenuous activity would increase spasticity and reinforce abnormal movement.

Table 2 Effect of muscle strengthening on walking. Inpatient conventional physical therapy No group difference in 2 minute walk test at 4 weeks, discharge and 6 months post discharge. Task-specific training to improve walking ability Stroke results in a number of deficits which may affect motor unit recruitment and rate coding, proprioception, viscoelastic characteristics of muscle and connective tissues, sense of effort, postural reflexes, vestibular function and vision.

Treadmill training The benefits from treadmill training may have neurophysiological underpinnings; spinalized animals demonstrate coordinated activation of spinal neural circuits from the alternating limb movements facilitated from a treadmill [ ].

Stroke patients regain sight after intensive brain training

Table 3 Effect of treadmill training on walking. Author Subjects Program description Results Early post-stroke inpatient rehabilitation Richards et al. BWSTT with 1 therapist for support and 1 therapist to assist with stepping movement. Task was progressed with increasing treadmill speed and reducing body-weight. Gradual reduction of support and increase in speed. Individual walking practice motor re-learning plus conventional rehabilitation.

No group difference for gait speed and functional ambulation category at discharge and 10 month follow-up. In addition, all 3 groups received 8 sessions of 45 min conventional physiotherapy. No group effects for gait speed. Less therapist assistance required for gait trainer. Therapy hours per group differed. Facilitation group required more resources. No group difference in gait speed or Functional ambulatory category after 4 weeks of training.

Lokomat group improved duration of single limb support time more than conventional physiotherapy. Low intensity home exercise of stretching and strengthening leg muscles, recommended daily walk, balance exercises. Treadmill aerobic training without body weight support. Intensive mobility training Given the many mechanisms which contribute to gait and the varying tasks and environments under which gait is utilized, an intervention that addresses different elements underlying walking and the broader framework of mobility might be optimal. Table 4 Effect of intensive mobility training on walking studies ordered chronologically.

Control Usual care Assisted and resisted exercises with theraband Functional exercises Balance exercises Progressive walking program or bicycle ergometer No group difference for 6MWT but trend for gait speed 0. Control Usual care Strengthening using theraband Balance: Arm exercises strengthening, reaching, stretching 10 stations 5 min each: Control Group Upper extremity program 10 stations 5 min each: Mobility in community pool Group 2: Resistance provided by water. Control Upper extremity program 10 tasks 5 min each, except 10 min treadmill: Control Weight-bearing and stretching Agility tasks: Eyes closed and foam surfaces were used for some of the tasks.

Mobility group reduced falls, while Control increased falls. For those with history of falls, Mobility subjects had less falls in the 1 year following study than Control subjects. Control with no treatment 6 stations 5 min each: Expert commentary The evidence suggests that the optimal program to improve walking ability involves repetitive and intensive practice which is continually incremented in difficulty according to the tolerance of the participant.

Five-year view In terms of future research, there is no doubt that the quality of clinical trials in this field will continue to improve. Key issues Impairments resulting from stroke, such as muscle weakness, incoordination, poor endurance, pain, spasticity and poor balance lead to persistent difficulties with walking.

Gait training interventions have potential to improve walking ability across the 3 levels of functioning Body Functions and Structures, Activities and Participation and it would be ideal to have outcome measures representing each level. Gait retraining through different types of exercise is the most common approach to improving walking ability.

Neurodevelopmental approaches were equivalent or inferior to other approaches to improve walking ability. Graded muscle strengthening not using functional activities has been found to improve muscle strength, but not transfer to improved walking ability. Treadmill training has been found to have equivalent effects to overground gait training in sub-acute rehabilitation, but beneficial effects compared to low intensity control groups in chronic stroke.

A combination of treadmill with task-specific practice may be optimal. Intensive mobility training which incorporates functional strengthening, balance and aerobic exercises and practice on a variety of walking tasks improves gait ability both in sub-acute and chronic stroke. Petrasovits A, Nair C. Epidemiology of stroke in Canada.

The influence of gender and age on disability following ischemic stroke: J Stroke Cerebrovasc Dis.

Stroke patients regain sight after brain training | Science | The Guardian

Intercollegiate Stroke Working Party. Residual disability in survivors of stroke--the Framingham study. N Engl J Med. Reduced ambulatory activity after stroke: Arch Phys Med Rehabil. Measurement and recovery over the first 3 months. Scand J Rehabil Med. Physical therapy during stroke rehabilitation for people with different walking abilities. Rehabilitation goals of patients with hemiplegia.

Int J Rehabil Res. Goal priorities identified by individuals with chronic stroke: Implications for rehabilitation professionals. Association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability. Transitions between frailty states among community-living older persons.

Long-term survival after stroke. Determinants of satisfaction with community reintegration in older adults with chronic stroke: Relationship between ambulatory capacity and cardiorespiratory fitness in chronic stroke: Key characteristics of walking correlate with bone density in individuals with chronic stroke. J Rehabil Res Dev. Determinants of walking function after stroke: Normal cardiorespiratory responses to acute aerobic exercise.

Lippincott Williams and Wilkins; Philadelphia: Analysis of impairments influencing gait velocity and asymmetry of hemiplegic patients after mild to moderate stroke. The relationship of lower-extremity muscle torque to locomotor performance in people with stroke. Functional walk tests in individuals with stroke: Analysis of the clinical factors determining natural and maximal gait speeds in adults with a stroke. Am J Phys Med Rehabil. Cardiorespiratory fitness and walking ability in subacute stroke patients.

Do functional walk tests reflect cardiorespiratory fitness in sub-acute stroke? Submaximal exercise in persons with stroke: Contribution of passive stiffness to ankle plantarflexor moment during gait after stroke. The relation between ankle impairments and gait velocity and symmetry in people with stroke. International Classification of Impairments, Disabilities and Health. World Health Organization; Comparing contents of functional outcome measures in stroke rehabilitation using the International Classification of Functioning, Disability and Health.

Classification of walking handicap in the stroke population. Reference equations for the six-minute walk in healthy adults. Reliability of gait performance tests in men and women with hemiparesis after stroke. Balance during obstacle crossing following stroke. Knee muscle strength, gait performance, and perceived participation after stroke.

Community ambulation after stroke: Accelerometer monitoring of home- and community-based ambulatory activity after stroke. Improvements in speed-based gait classifications are meaningful. Lord SE, Rochester L. Measurement of community ambulation after stroke: Garner C, Page SJ. Applying the transtheoretical model to the exercise behaviors of stroke patients.

Measurement properties of the Activities-specific Balance Confidence Scale among individuals with stroke. Development and psychometric properties of the ambulatory self-confidence questionnaire. Physical activity for people with a disability: Relationship of balance and mobility to fall incidence in people with chronic stroke.

The use of aerobic exercise training in improving aerobic capacity in individuals with stroke: Physiotherapy based on the Bobath concept for adults with post-stroke hemiplegia: Effects of augmented exercise therapy time after stroke: Gait retraining post stroke. Treadmill training and body weight support for walking after stroke. Cochrane Database Syst Rev. Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke. The impact of physical therapy on functional outcomes after stroke: Strength training in individuals with stroke.

Outcomes of progressive resistance strength training following stroke: EMG feedback and the restoration of motor control. A controlled group study of 12 hemiparetic patients. Am J Phys Med. Three exercise therapy approaches. Task-specific physical therapy for optimization of gait recovery in acute stroke patients. Comparison of two therapy approaches in rehabilitation of the pure motor hemiparetic stroke patient.

Langhammer B, Stanghelle JK. Bobath or motor relearning programme? A comparison of two different approaches of physiotherapy in stroke rehabilitation: Comparison of Bobath based and movement science based treatment for stroke: J Neurol Neurosurg Psychiatry. A Single-Blind, Randomized Trial.

Effects of isokinetic training on the rate of movement during ambulation in hemiparetic patients. Effects of isokinetic strength training on walking in persons with stroke: A double-blind controlled pilot study. Effect of force-feedback treatments in patients with chronic motor deficits after a stroke. Progressive resistance strengthening exercises after stroke: High-intensity resistance training improves muscle strength, self-reported function, and disability in long-term stroke survivors.

A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation. Comparison of partial body weight-supported treadmill gait training versus aggressive bracing assisted walking post stroke. Walking training of patients with hemiparesis at an early stage after stroke: The effect of treadmill training on the ambulation of stroke survivors in the early stages of rehabilitation: Speed-dependent treadmill training in ambulatory hemiparetic stroke patients: Gait outcomes after acute stroke rehabilitation with supported treadmill ambulation training: Treadmill training with partial body weight support and an electromechanical gait trainer for restoration of gait in subacute stroke patients: Treadmill training with partial body weight support and physiotherapy in stroke patients: The role of technology in task-oriented training in persons with subacute stroke: Does therapeutic facilitation add to locomotor outcome of body weight--supported treadmill training in nonambulatory patients with stroke?

A randomized controlled trial. Effects of locomotion training with assistance of a robot-driven gait orthosis in hemiparetic patients after stroke: Step training with body weight support: A treadmill and overground walking program improves walking in persons residing in the community after stroke: Stepping over obstacles to improve walking in individuals with poststroke hemiplegia. Treadmill exercise rehabilitation improves ambulatory function and cardiovascular fitness in patients with chronic stroke: A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke.

Randomized clinical trial of therapeutic exercise in subacute stroke. Blennerhassett J, Dite W. Additional task-related practice improves mobility and upper limb function early after stroke: Task-related circuit training improves performance of locomotor tasks in chronic stroke: Water-based exercise for cardiovascular fitness in people with chronic stroke: A task-orientated intervention enhances walking distance and speed in the first year post stroke: Exercise leads to faster postural reflexes, improved balance and mobility, and fewer falls in older persons with chronic stroke.

J Am Geriatr Soc. A community-based fitness and mobility exercise program for older adults with chronic stroke: Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke.

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A randomized controlled trial of supervised versus unsupervised exercise programs for ambulatory stroke survivors. Physiotherapy based on the Bobath concept in stroke rehabilitation: Treadmill training with partial body weight support compared with physiotherapy in nonambulatory hemiparetic patients. Restoration of gait by combined treadmill training and multichannel electrical stimulation in non-ambulatory hemiparetic patients. Marsden J, Greenwood R.

Gait outcome following outpatient physiotherapy based on the Bobath concept in people post stroke. Heinemann Medical Books Ltd; Isokinetic strength training of the hemiparetic knee: Spasticity and its association with functioning and health-related quality of life 18 months after stroke. Progressive resistance strength training for physical disability in older people. Resistance exercise and physical performance in adults aged 60 to Reduced hip bone mineral density is related to physical fitness and leg lean mass in ambulatory individuals with chronic stroke.

Acute and long-term increase in fracture risk after hospitalization for stroke. The origin of voluntary action: Barbeau H, Rossignol S. Recovery of locomotion after chronic spinalization in the adult cat. Clinical practice guidelines for gait training. Management of Adult Stroke Rehabilitation Care: Aerobic treadmill plus Bobath walking training improves walking in subacute stroke: Am J Occup Ther. A systematic review of the efficacy of gait rehabilitation strategies for SCI. Topics in Spinal Cord Rehabilitation.

Gaze fixation patterns for negotiating complex ground terrain. Exercise of personal and collective efficacy in changing societies. Self-Efficacy in Changing Societies. The beneficial effects of group-based exercises on fall risk profile and physical activity persist 1 year postintervention in older women with low bone mass: Physiotherapy for patients with mobility problems more than 1 year after stroke: Is dosage of physiotherapy a critical factor in deciding patterns of recovery from stroke: Intensity of leg and arm training after primary middle-cerebral-artery stroke: Physiotherapy intervention late after stroke and mobility.

Can augmented physiotherapy input enhance recovery of mobility after stroke? The effect of a task-oriented walking intervention on improving balance self-efficacy poststroke: Susceptibility to deterioration of mobility long-term after stroke: Impact of time on improvement of outcome after stroke. Barbeau H, Visintin M. Optimal outcomes obtained with body-weight support combined with treadmill training in stroke subjects.

A comparison of regular rehabilitation and regular rehabilitation with supported treadmill ambulation training for acute stroke patients. Support Center Support Center. Please review our privacy policy. No group differences in indoor ambulatory independence at 6 weeks post admission. All groups received conventional rehabilitation, plus one of three physiotherapy groups: Functional training passive range of motion, progressive resistive exercises even in the presence of spasticity, early use of assistive device and bracing.

Langhammer and Stranghelle [ 60 ] At 2 weeks after the first assessment and 3 months post-stroke, there was no group difference in the trunk, balance and gait subscale of the Sodring Motor Evaluation Scale. Van Vliet et al.

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Sessions were a median of 23 minutes for total of min Group 1: No group differences for any outcome including 6MWT, Rivermead Motor Asessment, Motor Asessement Scale used area under curve analysis at 1, 3 and 6 months after baseline. Glasser [ 63 ] No group difference in functional ambulation profile includes speed, number of steps, step length. Inpatient conventional physical therapy. No group difference in 2 minute walk test at 4 weeks, discharge and 6 months post discharge.

No group difference in 6MWT, stair climb, self-paced and maximal gait speed. Control Group of Treadmill without body-weight support. Kosak and Reding [ 69 ] No group differences for gait speed or distance over 6 weeks. Da Cunha Filho et al. Both groups had interdisciplinary rehabilitation. No group differences in gait speed at discharge or after 2 months therapy. BWSTT with assistance to paretic foot. No group difference in gait speed or FIM gait score at week 10 or week Assisted and resisted exercises with theraband Functional exercises Balance exercises Progressive walking program or bicycle ergometer.

All enrolled participants will be allocated a unique study ID, and the information linking their ID to their personal details will be kept securely at the University of Exeter. All other participant-related paper records will be anonymised and stored separately from the personal information.

The electronic database for the trial will be stored on the secure servers of the University of Exeter with password-controlled access provided for the research team by the Peninsula Clinical Trials Resource Unit. Single data entry with extensive in-built validity checks will be used to reduce the risk of transcription errors.

The study database will include prompts for missing data, and warnings to alert staff when values are entered that are outside of the expected range or are inconsistent with other data already entered, or if the type of value entered is incorrect eg, a numeric value entered rather than text. Video-recordings and audio-recordings will be digitised, encrypted and stored on the university secure server. Audio-recordings will be retained until after anonymised transcripts have been finalised and analysed. At this stage they will be securely and permanently deleted. Access to personal data will be restricted to the research team.

Names and participant details will not be passed onto any third parties and no named individuals will be included in the write up of the results. All participants stroke survivors and personal trainers will be asked for their consent for the study team to retain interviews and video-recordings for the purposes of future research by those involved directly in the study team or for educational purposes.

Data will also be subject to standard secure storage and usage policies. Trial progress will be reported to our SUG quarterly. At the end of the study, we will seek input from our SUG to help disseminate a lay summary of the findings to study participants. A trial publication policy will be developed. We envisage a number of key papers arising from this pilot trial.

The publication policy document will outline the strategic plan for dissemination. The results of the trial will be reported first to study collaborators and to the funder the Stroke Association. The sponsor and funder play no role in the study design, conduct, analyses, data interpretation or report writing.

The funder requires advance notification of any planned public dissemination activities but does not hold authority over these activities. The main report will be drafted by the TMG and circulated to all collaborators for comment. The final version will be agreed by the TSC before submission for publication, on behalf of all the ReTrain collaborators. Key outputs from the trial will contribute to our dissemination and impact agenda: SGD discloses textbook royalties from Wiley Blackwell for work outside the submitted work; all authors report the Stroke Association funding for the work under consideration.

All authors commented on the protocol and the manuscript. Provenance and peer review: Not commissioned; externally peer reviewed. National Center for Biotechnology Information , U. Published online Oct 3. Author information Article notes Copyright and License information Disclaimer. Correspondence to Professor Sarah Dean; ku. For permission to use where not already granted under a licence please go to http: This article has been cited by other articles in PMC. Abstract Introduction The Rehabilitation Training ReTrain intervention aims to improve functional mobility, adherence to poststroke exercise guidelines and quality of life for people after stroke.

Methods and analysis A 2-group, assessor-blinded, randomised controlled external pilot trial with parallel mixed-methods process evaluation and economic evaluation. Strengths and limitations of this study. This pilot randomised controlled trial study meets the Medical Research Council MRC guidance on the development and evaluation of complex interventions and includes comprehensive patient and public involvement. This preliminary evaluation of a late stage rehabilitation programme addresses the gap in the evidence related to what facilitates stroke recovery in the longer term.

This small scale study is designed to estimate effect sizes but has insufficient statistical power to detect differences in outcomes between groups. The follow-up period is relatively short compared with what would be planned for a fully funded definitive trial. Introduction Residual physical disability is common following discharge from stroke rehabilitation services.

Aims To undertake a study that will evaluate the feasibility and acceptability of procedures to inform the design and delivery of a definitive RCT of ReTrain which would assess the clinical and cost-effectiveness of ReTrain for stroke survivors. Methods and analysis Design A two-group, assessor-blinded, randomised controlled external pilot trial with parallel mixed-methods process evaluation and economic evaluation. Open in a separate window. Population Potential participants will be included if they meet the following inclusion and exclusion criteria: Acute or uncontrolled heart failure;.

Sample size The target recruitment number is 48 participants 24 per group. Participant recruitment Participants will be recruited and the programme delivered in two areas of Devon Exeter and South Devon. Via clinicians in NHS primary care, hospital and community stroke services: Early supported discharge teams;. Those responsible for conducting the 6-month review recommended by the National Stroke Strategy;.

Exeter Clinical Research Facility which maintains a database of health research-interested members of the public;. Letters, articles and posters will be used to provide brief details of the study and invite expressions of interest to contact the research team by telephone call, email or post. Promotion via local stroke support networks identified through national organisations such as the Stroke Association, Different Strokes and Connect, and via internet searches and in local media.

Randomisation and group allocation To ensure allocation concealment, participants will be allocated 1: Blinding Participants, personal trainers providing the intervention, and researchers conducting the process and economic evaluation cannot be blinded to allocation. Intervention ReTrain is a specified intervention that is based on ARNI but also draws on poststroke exercise guidelines, 9 our preliminary studies and stakeholder consultations; this combination makes it a novel intervention compared with other community exercise-based programmes.

Control All participants receive treatment as usual which will be recorded for both groups however, in addition, the control group will receive an advice booklet about exercise after stroke, based on a Stroke Association's publication. Assessment and outcomes Initial screening assessment Those expressing an interest in taking part in the study will be contacted by telephone by a member of the research team and, with their permission, be asked questions to assess their eligibility. Home-based screening and data collection Those apparently eligible for inclusion will be visited at home by a member of the research team to provide further information about the intervention and study, and to obtain written consent.

Demographic and other personal information will also be collected at this time: Date of birth, gender;. Clinical outcomes We will collect both the objective physical outcome and participant-reported outcome measures PROMs that we intend to collect in a definitive trial. Measure Time to administer Assessment mins 1 2 3 Primary Rivermead Mobility index 37 38 item, dichotomously scored measure of mobility disability. Feasibility, acceptability and process outcomes The feasibility of a definitive RCT will be determined by collecting and analysing the following pilot study data.

Usual care Participants in intervention and control arms may receive health and social care as part of their usual care, and these will be recorded using the Service Receipt Inventory. Service user involvement Stroke survivors, their partners and carers have been consulted at all stages of the work leading to this proposal. Data analysis Given the feasibility objectives of this pilot study, the focus of data analysis will be descriptive.

Study timeline The timetable for the research can be seen in table 2: Incentives and payments Incentive payments will also be made to control and intervention group participants and paid on two occasions: Adverse events In preliminary studies, several falls were recorded, though none required medical intervention. Trial monitoring and management Day-to-day running of the trial will be the responsibility of the trial manager.

Data management Data will be collected and retained in accordance with the UK Data Protection Act , and managed in accordance with the trial-specific standard operating procedure for data management. Dissemination and impact activities Trial progress will be reported to our SUG quarterly. Long-term neuropsychological and functional outcomes in stroke survivors: Int J Stroke ; 3: Coronary heart disease statistics: British Heart Foundation, Time to rethink long-term rehabilitation management of stroke patients.

Top Stroke Rehabil ; Self-reported long-term needs after stroke. Department of Health, Effectiveness of psychological interventions in chronic stage of stroke: Long-term disability after first-ever stroke and related prognostic factors in the Perth Community Stroke Study, — Intercollegiate Stroke Working Party. National clinical guideline for stroke. Royal College of Physicians, Synthesising practice guidelines for the development of community-based exercise programmes after stroke.

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