OK, nothing useful. But great weasel words used; may, unclear, can improve,
insufficient evidence.
Physical fitness training for stroke patients
David H Saunders1, Mark Sanderson2, Miriam Brazzelli3, Carolyn A Greig4, Gillian E Mead5
1Moray House School of Education, Institute for Sport, Physical Education and Health Sciences (SPEHS), University of Edinburgh, Edinburgh, UK. 2Institute of Clinical Exercise and Health Science, University of the West of Scotland, Hamilton, UK. 3Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK. 4School of Sport, Exercise and Rehabilitation Sciences, MRCARUK Centrefor Musculoskeletal Ageing Research,University of Birmingham, Birmingham, UK. 5Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
Contact address: David H Saunders, Moray House School of Education, Institute for Sport, Physical Education and Health Sciences (SPEHS), University of Edinburgh, St Leonards Land, Holyrood Road, Edinburgh, Midlothian, EH8 2AZ, UK. Dave.Saunders@ed.ac.uk.
Editorial group: Cochrane Stroke Group. Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 10, 2013. Review content assessed as up-to-date: 31 January 2013.
Citation: Saunders DH, Sanderson M, Brazzelli M, Greig CA, Mead GE. Physical fitness training for stroke patients. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD003316. DOI: 10.1002/14651858.CD003316.pub5.
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1Moray House School of Education, Institute for Sport, Physical Education and Health Sciences (SPEHS), University of Edinburgh, Edinburgh, UK. 2Institute of Clinical Exercise and Health Science, University of the West of Scotland, Hamilton, UK. 3Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK. 4School of Sport, Exercise and Rehabilitation Sciences, MRCARUK Centrefor Musculoskeletal Ageing Research,University of Birmingham, Birmingham, UK. 5Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
Contact address: David H Saunders, Moray House School of Education, Institute for Sport, Physical Education and Health Sciences (SPEHS), University of Edinburgh, St Leonards Land, Holyrood Road, Edinburgh, Midlothian, EH8 2AZ, UK. Dave.Saunders@ed.ac.uk.
Editorial group: Cochrane Stroke Group. Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 10, 2013. Review content assessed as up-to-date: 31 January 2013.
Citation: Saunders DH, Sanderson M, Brazzelli M, Greig CA, Mead GE. Physical fitness training for stroke patients. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD003316. DOI: 10.1002/14651858.CD003316.pub5.
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability.
Objectives
To determine whether fitness training after stroke reduces death, dependence, and disability. The secondary aims were to determine the effects of training on physical fitness, mobility, physical function, quality of life, mood, and incidence of adverse events.
Search methods
We searched the Cochrane Stroke Group Trials Register(lastsearchedJanuary2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12: searched January 2013), MEDLINE (1966 to January 2013), EMBASE (1980 to January 2013), CINAHL (1982 to January 2013), SPORTDiscus (1949 to January 2013), and five additional databases (January 2013). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field.
Selection criteria
Randomised trials comparing either cardiorespiratory training or resistance training, or both, with no intervention, a non-exercise intervention, or usual care in stroke survivors.
Data collection and analysis
Two review authors independently selected trials, assessed quality, and extracted data. We analysed data using random-effects metaanalyses. Diverse outcome measures limited the intended analyses.
Main results
We included 45 trials, involving 2188 participants, which comprised cardiorespiratory (22 trials, 995 participants), resistance (eight trials, 275 participants), and mixed training interventions (15 trials, 918 participants). Nine deaths occurred before the end of the intervention and a further seven at the end of follow-up. No dependence data were reported. Diverse outcome measures made data pooling difficult. Global indices of disability show a tendency to improve after cardiorespiratory training (standardised mean difference (SMD) 0.37, 95% confidence interval (CI) 0.10 to 0.64; P = 0.007); benefits at follow-up and after mixed training were unclear. There were insufficient data to assess the effects of resistance training.
Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 7.37 metresper minute, 95% CI 3.70 to 11.03), preferred gait speed (MD 4.63 metres per minute, 95% CI 1.84 to 7.43), walking capacity (MD 26.99 metres per six minutes, 95% CI 9.13 to 44.84), and Berg Balance scores (MD 3.14, 95% CI 0.56 to 5.73) at the end of the intervention. Mixed training, involving walking, increased preferred walking speed (MD 4.54 metres per minute, 95% CI 0.95 to 8.14), walking capacity (MD 41.60 metres per six minutes, 95% CI 25.25 to 57.95), and also pooled balance scores but the evidence is weaker (SMD 0.26 95% CI 0.04 to, 0.49). Some mobility benefits also persisted at the end of follow-up. The variability and trial quality hampered the assessment of the reliability and generalisability of the observed results.
Authors’ conclusions
The effects of training on death and dependence after stroke are unclear. Cardiorespiratory training reduces disability after stroke and this may be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programs to improve the speed and tolerance of walking; improvement in balance may also occur. There is insufficient evidence to support the use of resistance training. Further well-designed trials are needed to determine the optimal content of the exercise prescription and identify long-term benefits.
PLAIN LANGUAGE SUMMARY
Physical fitness training for stroke patients
Physical fitness is important to allow people to carry out everyday activities such as walking and climbing stairs. However, physical fitness is often reduced in stroke patients and may limit their ability to perform everyday activities and also worsen any stroke-related disability. For this reason fitness training has been proposed as a beneficial approach for stroke patients. In January 2013 this review identified 45 trials involving 2188 participants, which tested different forms of fitness training after stroke.
Studies of fitness training can be difficult to carry out. This means most of the studies were small and of moderate quality. However, some consistent findings did emerge. We found that some types of fitness training, particularly those involving walking, can improve exercise ability, walking and balance after stroke. However, there was not enough information to draw reliable conclusions about the impact of fitness training on quality of life or mood.
There was no evidence that any of the different types of fitness training caused injuries or other health problems; exercise appears to be a safe intervention.
Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability.
Objectives
To determine whether fitness training after stroke reduces death, dependence, and disability. The secondary aims were to determine the effects of training on physical fitness, mobility, physical function, quality of life, mood, and incidence of adverse events.
Search methods
We searched the Cochrane Stroke Group Trials Register(lastsearchedJanuary2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12: searched January 2013), MEDLINE (1966 to January 2013), EMBASE (1980 to January 2013), CINAHL (1982 to January 2013), SPORTDiscus (1949 to January 2013), and five additional databases (January 2013). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field.
Selection criteria
Randomised trials comparing either cardiorespiratory training or resistance training, or both, with no intervention, a non-exercise intervention, or usual care in stroke survivors.
Data collection and analysis
Two review authors independently selected trials, assessed quality, and extracted data. We analysed data using random-effects metaanalyses. Diverse outcome measures limited the intended analyses.
Main results
We included 45 trials, involving 2188 participants, which comprised cardiorespiratory (22 trials, 995 participants), resistance (eight trials, 275 participants), and mixed training interventions (15 trials, 918 participants). Nine deaths occurred before the end of the intervention and a further seven at the end of follow-up. No dependence data were reported. Diverse outcome measures made data pooling difficult. Global indices of disability show a tendency to improve after cardiorespiratory training (standardised mean difference (SMD) 0.37, 95% confidence interval (CI) 0.10 to 0.64; P = 0.007); benefits at follow-up and after mixed training were unclear. There were insufficient data to assess the effects of resistance training.
Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 7.37 metresper minute, 95% CI 3.70 to 11.03), preferred gait speed (MD 4.63 metres per minute, 95% CI 1.84 to 7.43), walking capacity (MD 26.99 metres per six minutes, 95% CI 9.13 to 44.84), and Berg Balance scores (MD 3.14, 95% CI 0.56 to 5.73) at the end of the intervention. Mixed training, involving walking, increased preferred walking speed (MD 4.54 metres per minute, 95% CI 0.95 to 8.14), walking capacity (MD 41.60 metres per six minutes, 95% CI 25.25 to 57.95), and also pooled balance scores but the evidence is weaker (SMD 0.26 95% CI 0.04 to, 0.49). Some mobility benefits also persisted at the end of follow-up. The variability and trial quality hampered the assessment of the reliability and generalisability of the observed results.
Authors’ conclusions
The effects of training on death and dependence after stroke are unclear. Cardiorespiratory training reduces disability after stroke and this may be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programs to improve the speed and tolerance of walking; improvement in balance may also occur. There is insufficient evidence to support the use of resistance training. Further well-designed trials are needed to determine the optimal content of the exercise prescription and identify long-term benefits.
PLAIN LANGUAGE SUMMARY
Physical fitness training for stroke patients
Physical fitness is important to allow people to carry out everyday activities such as walking and climbing stairs. However, physical fitness is often reduced in stroke patients and may limit their ability to perform everyday activities and also worsen any stroke-related disability. For this reason fitness training has been proposed as a beneficial approach for stroke patients. In January 2013 this review identified 45 trials involving 2188 participants, which tested different forms of fitness training after stroke.
Studies of fitness training can be difficult to carry out. This means most of the studies were small and of moderate quality. However, some consistent findings did emerge. We found that some types of fitness training, particularly those involving walking, can improve exercise ability, walking and balance after stroke. However, there was not enough information to draw reliable conclusions about the impact of fitness training on quality of life or mood.
There was no evidence that any of the different types of fitness training caused injuries or other health problems; exercise appears to be a safe intervention.
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