The effects of increased dose of exercise-based therapies to enhance motor recovery after stroke: a systematic review and meta-analysis

Abstract

BackgroundExercise-based therapy is known to enhance motor recovery after stroke but the most appropriate amount, i.e. the dose, of therapy is unknown. To determine the strength of current evidence for provision of a higher dose of the same types of exercise-based therapy to enhance motor recovery after stroke.MethodsAn electronic search of: MEDLINE, EMBASE, CINHAL, AMED, and CENTRAL was undertaken. Two independent reviewers selected studies using predetermined inclusion criteria: randomised or quasi randomised controlled trials with or without blinding of assessors; adults, 18+ years, with a clinical diagnosis of stroke; experimental and control group interventions identical except for dose; exercise-based interventions investigated; and outcome measures of motor impairment, movement control or functional activity. Two reviewers independently extracted outcome and follow-up data. Effect sizes and 95% confidence intervals were interpreted with reference to risk of bias in included studies.Results9 papers reporting 7 studies were included. Only 3 of the 7 included studies had all design elements assessed as low risk of bias. Intensity of the control intervention ranged from a mean of 9 to 28 hours over a maximum of 20 weeks. Experimental groups received between 14 and 92 hours of therapy over a maximum of 20 weeks. The included studies were heterogeneous with respect to types of therapy, outcome measures and time-points for outcome and follow-up. Consequently, most effect sizes relate to one study only. Single study effect sizes suggest a trend for better recovery with increased dose at the end of therapy but this trend was less evident at follow-up Meta-analysis was possible at outcome for: hand-grip strength, -10.1 [-19.1,-1.2] (2 studies, 97 participants); Action Research Arm Test (ARAT), 0.1 [-5.7,6.0] (3 studies, 126 participants); and comfortable walking speed, 0.3 [0.1,0.5] (2 studies, 58 participants). At follow-up, between 12 and 26 weeks after start of therapy, meta-analysis findings were: Motricity Arm, 10.7 [1.7,19.8] (2 studies, 83 participants); ARAT, 2.2 [-6.0,10.4] (2 studies, 83 participants); Rivermead Mobility, 1.0 [-0.6, 2.5] (2 studies, 83 participants); and comfortable walking speed, 0.2 [0.0,0.4] (2 studies, 60 participants).ConclusionsCurrent evidence provides some, but limited, support for the hypothesis that a higher dose of the same type of exercised-based therapy enhances motor recovery after stroke. Prospective dose-finding studies are required.

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

“…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 .…”

Elaboração de um manual ilustrado de exercícios domiciliares para pacientes com hemiparesia secundária ao acidente vascular encefálico (AVE)

“…Foi orientada a realização diária domiciliar, tendo em vista que a repetição influencia no aprendizado motor 13 . Foi observado que 91% dos pacientes realizaram os exercícios orientados mais de três vezes por semana, mantendo, portanto, alta frequência de treinamento, o que pode resultar em ganhos funcionais e maior qualidade de vida 6,14,26 . Sobre o tempo de reavaliação para analisar a adesão ao exercício, não há suporte na literatura.…”

“…Programas de fortalecimento e condicionamento físico têm demonstrado resultados positivos no que diz respeito aos ganhos de força 7,8 , marcha 9 , mobilidade 10 e função 11 em pacientes pós AVE. A American Heart Association recomenda que esses pacientes realizem atividades físicas regularmente, alegando melhora cardiorrespiratória, motora e funcional 12 . O aumento da frequência dos exercícios contribui para a aprendizagem motora, além de otimizar o ganho de força e condicionamento físico com consequente melhora funcional 13,14 . No entanto, o custo financeiro da reabilitação é alto para os pacientes e ór-gãos de saúde 15,16 .…”

Relationship between Physical Activity and Stroke: Review From Different Meta Analytical Studies

“…These novel findings provide strong evidence supporting bilateral arm training with the caveat that two coupled protocols, rhythmic alternating movements and active stimulation, are most effective. 21 had done a systematic review and meta-analysis on the effects of increased dose of exercise-based therapies to enhance motor recovery after stroke from 9 papers reporting 7 , 60 participants).Current evidence provides some, but limited, support for the hypothesis that a higher dose of the same type of exercisedbased therapy enhances motor recovery after stroke. Prospective dose-finding studies are required.…”