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The effects of exercise-based rehabilitation on balance and gait for stroke patients: a systematic review.

ABSTRACT

This review evaluated the effects of balance and/or gait exercise interventions for stroke survivors and summarized the available evidence on these exercise interventions. A search for studies published between January 2001 and January 2010 was performed using the keywords stroke, walking or balance, and physical activity or exercise. Seventeen randomized clinical trials were identified. The findings suggest that initiating early rehabilitation during acute to subacute stroke recovery can improve balance and walking capacity. The findings also demonstrate that at least 1 hour, three to five times per week, of balance training and 30 minutes, three to five times per week, of gait-oriented exercise are effective to improve balance and walking. This review confirms that balance and walking capacity are improved with specific exercise modalities. A combination of balance, gait, and aerobic exercises would be ideal.

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Stroke is a leading cause of long-term functional disability in the United States. Among stroke survivors, about 15%-30% are permanently disabled and 20% still require institutional care at 3 months after onset, indicating dependence on others to perform their daily activities, because of impaired arm and hand function and impaired walking ability (Lloyd-Jones et al., 2010). These impairments can lead to reduced activity and sedentary lifestyles. Therefore, rehabilitation is essential for stroke survivors to optimally recover mobility and functional abilities so that they can live independently, participate in the community, and experience fewer secondary complications.

Restoration of independent gait and balance is a main aim of rehabilitation for patients living with stroke, because it is associated with independent mobility and reduced fall risk (Lamb, Ferrucci, Volapto, Fried, & Guralnik, 2003). Physical activity and exercise have been established to be beneficial to stroke patients in terms of improvement in walking ability and balance (Gordon et al., 2004). Many studies have reported that various exercise programs, such as gait-oriented training (van de Port, Wood-Dauphinee, Lindeman, & Kwakkel, 2007), aerobic treadmill training (Hesse, 2008; Hesse, Werner, von Frankenberg, & Bardeleben, 2003), intensive mobility training (Eng & Tang, 2007), and physiotherapeutic interventions (Hammer, Nilsagard, & Wallquist, 2008), are beneficial in improving walking and balance ability for stroke survivors.

However, there is limited information regarding specific exercise types and prescriptions for stroke survivors in different phases of recovery. It is necessary to establish such exercise recommendations and support them with scientific evidence, because these factors may dramatically affect rehabilitation outcomes. Therefore, the purpose of this review was to evaluate the effects of exercise interventions focused on balance and/or gait and to summarize the available evidence on exercise interventions to optimize mobility outcomes for stroke survivors.

Method

Literature Search

A search was conducted for studies, including systematic reviews and meta-analyses, and recent studies published between 2001 and January 2010. Databases searched were MEDLINE, PubMed, and CINAHL. The following keywords were used: stroke, gait or balance, and physical activity or exercise.

Selection Criteria

The search was limited to randomized controlled trials (RCTs) published in the English language involving adults living with stroke. The following inclusion criteria were applied: (a) participants living with stroke who were 18 years and older and (b) one of the outcomes focused on balance or gait functions, such as walking distance or walking speed. The exclusion criteria were as follows: (a) studies using robotic devices or virtual reality therapy or (b) clinical observation or case study. The methodological quality was rated using the Physiotherapy Evidence Database (PEDro) Scale (see Table 1). The PEDro Scale uses 11 items to assess the characteristics of RCTs for comparison in systematic reviews. PEDro scores of 6 points or higher were classified as high quality, and scores of 5 points or lower were of lower quality, with a cutoff at 4 points for acceptable quality (Maher, Sherrington, Herbert, Moseley, & Elkins, 2003).

All titles were screened for relevant studies, and abstracts were chosen from the relevant titles. Abstracts were then reviewed for concurrence with inclusion criteria. From the remaining abstracts, full text articles were reviewed, and during the review, those that did not meet the inclusion criteria were excluded as well.

Results

Over 353 titles were retrieved from the database sources, and 56 abstracts were identified for possible inclusion. During screening of titles, studies were excluded for the following reasons: nonrandomized design, no control group, inappropriate patient population, inappropriate intervention, and inappropriate outcome. On examination of the abstracts, 39 studies were excluded for the reasons stated above. Seventeen studies were reviewed, which provided information on a 1,105 stroke survivors.

Study Characteristics and Quality

Sample sizes of the studies reviewed varied widely from 14 to 136 patients (median, 60 patients), and most participants in the trials were 60 years and older (range, 27-87 years), with at least minimal gait impairment resulting from stroke. The time between stroke onset and the start of the intervention ranged from less than 10 days to over 1 year. With the time point of 1 and 6 months poststroke serving as the cutoff points between these categories, the recovery phase was divided into acute (within 1 month), subacute (less than 6 months), and chronic (6 months or more). Details of the methodological quality are presented in Table 1, and PEDro scores ranged from 4 to 8 points.

Balance

Ten studies used RCTs to examine the effects of exercise programs on balance in patients with stroke. These studies were performed in the chronic phase of stroke recovery (n = 7), subacute phase (n = 2), and acute phase (n = 1). Most of the trials (17--8) assessed balance using the Berg Balance Scale (BBS), which is composed of 14 tasks that assess balance in older adults. Scores range from 0 to 56: scores of 0 to 20 indicate balance impairment, 21 to 40, acceptable balance, and 41 to 56, good balance (Berg, Wood-Dauphinee, & Williams, 1995). An increase of 7.7 BBS points is required to reveal a genuine change in function for a participant (Conradsson et al., 2007). The variety of exercise programs that post-stroke individuals underwent was handled by dividing the exercise programs into three categories: aerobic, comprehensive, and multisensory exercise.

Aerobic Exercises to Improve Balance

Au-Yeung, Hui-Chan, and Tang (2009) recruited 136 chronic stroke patients with manifestation of hemiplegia. The patients in the experimental group (n = 62) participated in tai chi exercise, 1 hour of group practice and 3 hours of self-practice per week. The control group (n = 74) received general exercise training with similar duration and schedules to the experimental group. After the training, the tai chi exercise group showed greater shifting center of gravity movements than the control group when leaning forward, backward, and toward the unaffected and affected side at the end of the 12-week program. The benefits were still present after an additional 6 weeks. Neither the experimental group nor the control group had significant improvements in functional mobility assessed with the Timed Up and Go test (-1.9 and -2.2 seconds, respectively). The results indicated that tai chi exercise improved standing balance control but did not affect walking speed or ability to turn around.

Barbeau and Visintin (2003) conducted a 6-week locomotor training in subacute patients with hemiparesis. One hundred stroke survivors were randomly assigned to either locomotor training with body weight support (BWS; n = 50) or locomotor training with full-weight bearing (non-BWS; n = 50) by block randomization within strata identified based on initial level of ambulatory status. Participants in both groups exercised four times per week for 6 weeks. The stratified subjects with severely impaired pretraining scores in the BWS showed significant improvement in balance, walking speed, and walking endurance over those in the control group (p < .05). After stratification by age to 20-65 and 65-85 years, older people (65-85 years) in the BWS group showed significantly greater improvement in balance and motor recovery. The results indicate that the improvement in balance produced by gait-oriented exercise accompanied walking capacity.

Yen, Wang, Liao, Huang, and Yang (2008) randomly allocated 14 chronic stroke patients to an experimental group that received 4 weeks of BWS treadmill training after 4 weeks of general physical therapy (n = 7) and a control group that received physical therapy only (n = 7). The treadmill training was provided in a 30-minute session, three times per week. After training, both groups improved balance, as assessed by BBS, but there was no significant difference between the groups (+2.1 and +1.0, respectively). Considering the baseline balance scores for the samples, the participants in the experimental group and the control group had already good balance, with mean scores of 50.57 and 50.29, respectively. In addition, the study was likely underpowered because of the small sample size. To examine the effect of treadmill training on balance, further research is needed--another repeat study in the population with balance impairments.

In a pilot study, Noh, Lim, Shin, and Paik (2008) evaluated the effects of 8 weeks of aquatic therapy in 25 chronic stroke patients with hemiparesis. The training lasted 1 hour, three times per week. Conventional therapy, including extremity strengthening and gait training, was provided to control group (n = 12) with the same frequency and duration. The aquatic exercise group (n = 13) had an increase of 7.6 BBS points compared with the 2.2-points increase in the control group (p < .05). In addition, significant improvement in forward and backward weight bearing abilities of the affected limbs and knee flexor strength were observed in the aquatic exercise group. The result, 7.6 increases in BBS scores within 2 months, indicates that aquatic therapy has a genuine effect to improve balance in chronic stroke patients. However, the pilot study results have limited generalizability because of small sample sizes.

These findings from the above four RCTs provide evidence that aerobic exercise positively affects balance in subacute to chronic stroke patients with hemiparesis. The findings also suggest that improved balance in stroke survivors can be attained with exercise performed at least 20 minutes to 1 hour, three to four times a week, for 6-12 weeks.

Comprehensive Exercises to Improve Balance

Duncan et al. (2003) randomized 44 and 48 subacute stroke patients to experiment and control groups, respectively. The experiment group received a structured, progressive, physiologically based, therapist-supervised home exercise program, and the control group received conventional care. The participants received 90 minutes of exercise, 36 sessions, for 12-14 weeks. A significant improvement in BBS from 42.85 to 47.2 (+4.36 points) was observed after the 12-week exercise program compared with the improvement in BBS of 1.70 points (43.1-44.8) in the control group. Secondary stroke occurred in three participants (4%) who were all in the experimental group, but none of these occurred during the treatment sessions and all three returned home. The findings demonstrate that this kind of "one-on-one" comprehensive home-based exercise program improves balance in subacute stroke survivors.

Langhammer, Stanghelle, and Lindmark (2009) conducted an intensive exercise program with components of endurance, strength, and balance for the experimental group (n = 35). The control group (n = 40) did self-initiated exercise and did not receive encouragement from the researchers. The exercise program was initiated at an average of 16-22 days after stroke and took place 40-60 minutes, two to three times a week for 40 weeks. Both groups received 1 hour of general physiotherapy for 20 sessions. The groups had an average gain of 12.4 (26.0-38.4) and 15.8 (32.9-48.7) points in BBS, meaning that the first year of exercise brought the participants from acceptable to good balance. However, the results showed no difference between the groups at 3-, 6-, and 12- month follow up. Interestingly, an improvement was noted up to 6 months and was followed by a slight decline over the last 6 months of the study in the experimental group, but continuous improvement was noted in the control group. The findings suggest that early rehabilitation after stroke is effective in balance restoration, and simple, self-initiated exercise in the first year poststroke is as effective as intensive exercise if accessible exercises are available.

Pang, Eng, Dawson, McKay, and Harris (2005) studied 63 chronic stroke patients who were 50 years and older. The experimental group (n = 32) participated for 1 hour, three times per week, for 19 weeks of fitness and mobility exercise. The control group (n = 31) participated in a seated upper extremity program. The control group had similar improvements in balance to the experimental group (+2.0 and +1.9, respectively). There was no significant difference in the BBS between the two groups. This finding may be due to involved trunk stability and reaching function improvements through upper extremity training impact on balance. However, this small increase in BBS may come from a time effect for 19 weeks rather than genuine exercise effects.

The findings from the above three RCTs provide evidence that early initiation of exercise after stroke is effective in improving balance in stroke survivors, and there is evidence of longer-term benefits of the regular exercise in stroke survivors.

Multisensory Training to Improve Balance

Bayouk, Boucher, and Leroux (2006) studied 16 chronic patients with hemiparesis resulting from stroke. A task-oriented exercise program was provided to both groups (n = 8, respectively). The experimental group received additional multisensory training for 1 hour, two times a week, for 8 weeks. Center of pressure variability and total excursion on a pressure sensing floor mat were used to evaluate static and dynamic balance. There was no significant difference in balance between the two groups. This study showed that the intervention combining task-oriented exercise and multisensory training tended to improve balance, which was assessed by the center of pressure displacement scores, but the combined program did not lead to greater improvement in balance for hemiparetic subjects. Small sample size might have made it difficult to detect a statistical significance in postural weight bearing.

Marigold et al. (2005) compared the effects of 10-week agility exercise to stretching or weight-shifting exercise in chronic stroke patients who were 50 years and older. The experimental group received training in agility exercise in multisensory approach program for 1 hour, three times per week. Both the experimental group (n = 30) and the control group (n = 31) showed improvements in balance (+4.4 and +3.3, respectively), as measured by the BBS, but there was no significant difference between the groups. A significant improvement in step reaction time was found in agility exercise group than in stretching or weight-bearing group. The results illustrate that the agility exercise would be beneficial in reducing falls in chronic stroke patients who have altered motor coordination.

Yelnik et al. (2008) randomized 68 patients who had experienced a recent stroke but had reached the chronic recovery period (average of 7 months post-event). The experimental group (n = 33) patients received multisensorial training, and the control group (n = 35) received neurodevelopmental theory-based treatment for 1 hour, 5 days a week, for 4 weeks. Multisensorial training focused attention on the amount of exercise, such as duration and intensity, rather than the quality of the movement. Both the experimental group and the control group showed improvements on balance measured by BBS (+4.0 and +6.0, respectively), but there was no significant difference between the two groups. The results indicate that the superiority of the multisensorial approach training is not evident in this group of chronic stroke patients, and additional research may consider an approach more focused on quality of movement rather than amount of movement in multisensorial training.

The findings from the three RCTs showed similar trends. Both the experimental and the control groups improved balance, but there was no significant difference between the two groups. The three RCTs indicated that multisensorial interventions do not seem to be effective in improving balance in stroke survivors. On the basis of the literature reviewed regarding interventions targeting balance restoration, initiating early rehabilitation after stroke is important in acute stroke survivors. Moreover, well-structured home-based exercise is beneficial to restore additional balance in subacute stroke survivors at home after discharge from acute rehabilitation. Aerobic exercise also has shown to be beneficial to maintain and improve balance in chronic survivors.

Walking Ability

Ten studies evaluated the effects of an exercise program focused on walking speed or walking distance in participants in the acute to chronic stroke phases. These studies were conducted in the acute phase of stroke recovery (n = 2), subacute phase (n = 3), and chronic phase (n = 5). Most of the interventions were aimed at improving walking speed and were performed in the community. The prevailing type of exercise to improve walking ability was treadmill walking. Walking speed (m/s) was generally assessed using the timed 10-meter walk test (10MWT) or 6-minute walk test (6MWT), and walking distance was assessed using the 6MWT.

Using a classification of gait velocity validated for stroke survivors (Schmid et al., 2007), the participants' ambulation level in the following studies was stratified to household ambulation (<0.4 m/s), limited community ambulation (0.4-0.8 m/s), and full-community ambulation (>0.8 m/s). Among the 739 participants in the 11 trials, most patients had limited community ambulation (n = 607, 82.1%), 9.2% of the patients (n = 68) had household ambulation, and the remaining 8.6% had full-community ambulation. All participants had slower speed compared with the average healthy older adult's walking speed, which is 1.28 m/s (Laufer, Dickstein, Chefez, & Marcovitz, 2001). Their initial walking speed before their interventions ranged from 0.18 to 0.92 m/s and changed from 0.33 to 1.04. In this review, the exercise types were categorized as task-oriented exercise, intensive exercise, and dual-task exercise.

Gait-Oriented Exercise

Eight studies assessed walking speed and/or walking distance of stroke survivors from acute to chronic phase after they took part in treadmill walking. Various combinations of the treadmill walking training have been studied.

Treadmill walking with BWS versus general physical therapy. Yen et al. (2008) investigated the effects of additional gait training with 4-week treadmill training after a 4-week general physical therapy in chronic survivors averaging 2 years poststroke. Of 14 chronic stroke subjects with limited community ambulation, seven were randomized to the experimental group, which received a 4-week treadmill training (30 minutes, 3 times per week) with BWS after general physical therapy, and the remaining seven were randomized to the control group, which received only general physical therapy. After the intervention, both the experimental and the control groups improved walking speed (+23.58 and +8.35 cm/s, respectively), but the change in scores of walking speed was much higher in the experimental group, improving from 68.66 (+32.8) to 92.24 (+32.34) cm/s in walking speed, compared with the control group, which improved from 78.44 ([+ or -] 43.49) to 86.79 ([+ or -] 43.00) cm/s (p = .004). The results indicate that treadmill training combined with a conventional rehabilitation program provides additional benefit in improvement in walking speed in chronic stroke.

Treadmill walking with BWS versus overground walking. Two RCTs compared treadmill walking exercise with BWS to overground walking in acute and subacute stroke individuals.

Franceschini et al. (2009) randomized 92 patients who were within 60 days poststroke and had limited community ambulation to an experimental group (n = 52) and a control group (n = 45). The experimental group (n = 52) received a 20-minute BWS treadmill training plus a 40-minute overground walking training, 5 days per week, for 4 weeks, whereas the control group (n = 45) received a 60-minute overground walking training with the same frequency and duration. Both the experimental and control groups showed meaningful improvements in walking speed (+0.3 and +0.4 m/s, respectively) and distance (+67 and +70 m, respectively), but no significant differences were found between the groups. These results demonstrate that an early rehabilitation program contributed improvements in walking capacity, resulting in transitions from limited community ambulation to full-community ambulation. However, the modality of treadmill training, adding 20 minutes of treadmill training with BWS to the overground walking, was not superior to 1 hour overground walking modality.

Peurala et al. (2009) randomized 43 acute stroke patients with household ambulation ability to body weight supported treadmill training on a gait trainer (n = 22) and overground walking exercise (n = 21). The two exercise groups exercised a maximum of 1 hour to achieve 20 minutes of actual walking, 5 days a week, for 3 weeks in combination with physiotherapy. Both the treadmill and overground walking exercise groups improved walking speed (+0.42 m/s, +0.45 m/s, respectively) and walking distance (+124.8 meters, + 150.7 meters, respectively) but there was no significant change between the two groups. These results indicate that the early intensive walking is beneficial to improve walking ability, resulting in transition from household ambulation to limited community ambulation. The treadmill training with BWS and the overground walking were equally effective in improving walking ability.

The results of both studies suggest that stroke patients should participate in early rehabilitation to regain walking ability.

Treadmill walking with BWS versus without BWS. Barbeau and Visintin (2003) studied 100 subacute stroke patients with household ambulation. The patients were block-randomized to the experimental group (n = 50) and the control group (n = 50) by baseline ambulation speed. The experimental group received a 6-week treadmill training (4 times per week) with BWS, and the control group received the same schedule of treadmill training with full-weight bearing. After the training, the experimental group had significantly greater improvement in walking speed and walking distance, with more impaired subjects showing the most improvement in overground walking speed (p < .05). These results demonstrate that treadmill training with BWS leads to improved overground walking ability in subacute stroke survivors with severe walking deficits.

Treadmill walking without BWS versus overground walking. The following three RCTs evaluated treadmill walking without BWS compared with overground walking exercise.

Langhammer and Stanghelle (2010) compared treadmill training without BWS with overground walking in chronic stroke survivors with full-community ambulation. Both the experimental (n = 21) and the control (n = 18) groups performed 30 minutes, 5 days a week, for about 2.5 weeks, while they attended a private rehabilitation center. Participants in both groups received general physical therapy. After the treadmill training, the experimental group had a 0.2 m/s increase in walking speed measured by the 10MWT, a 0.1 m/s increase by the 6MWT, and a 31-m improved walking distance by the 6MWT, compared to the control group with overground walking training (+0.1 m/s, +0.1 m/s, and +24.1 m, respectively). The findings showed that treadmill walking improves spatial and temporal gait characteristics in stroke patients more effectively than walking outdoors.

Laufer et al. (2001) randomized 25 stroke survivors within 90 days from stroke with household ambulation to the experimental group (n = 13) and the control group (n = 12). Eight nondisabled, age-matched participants were recruited to provide for normal values. The experimental group received treadmill training without BWS and the control group received floor walking training for 3 weeks. In addition, both groups received Bobath approach physical therapy five times a week during the 3 weeks. Both groups started to exercise on the treadmill 4 minutes per day during the first week and increased to 2-minute increments every week for 3 weeks. Compared with the healthy subjects with same age, all the participants had slower walking speed and shorter stride length. Both the experimental and the control groups showed greater improvements in walking speed (+0.27 and +0.15m/s, respectively), but the changes were not significantly different. However, combining treadmill training with conventional physical therapy lead to clinically meaningful improvement in transitions from household ambulation (0.20 m/s) to limited community ambulation (0.47 m/s) compared with the overground walking with physical therapy (0.18-0.33 m/s).

Macko et al. (2005) randomized 61 chronic stroke survivors with limited community ambulation to the experimental group (n = 32), which received a treadmill aerobic training intervention program, and the control group (n = 29), which received a reference exercise program composed of stretching plus low-intensity walking exercise. Both the groups performed exercises for 40 minutes per session, three times per week, for 6 months. The experimental and control groups showed significant improvement in the 30-feet usual walking speed (+0.11 and +0.09 m/s, respectively) and fast walking speed (+0.13 and +0.10 m/s). However, there was no significant difference in walking speed between the two groups. Significant improvement in walking distance measured by the 6MWT (+160 feet = 49 m) was observed in the experimental group compared with the control group (+20 feet = 6 m and +6 points, respectively). The result demonstrates that, in chronic stroke survivors, the treadmill training with longer training sessions translated to improved overground walking distance but not improved walking speed.

The results showed that both exercises were effective in improving walking ability, but there was conflicting evidence about which modality of exercise was more effective.

Structured speed-dependent treadmill walking versus physiotherapeutic gait therapy. Pohl, Mehrholz, Ritschel, and Ruckriem, (2002) compared the effects of a 4-week structured speed-dependent treadmill training (STT) to limited progressive treadmill training (LTT) and to conventional gait training (CGT) in subacute stroke patients with limited community ambulation. The 60 participants were randomly assigned to one of the three groups by block randomization on the basis of the initial 10MWT. The STT group (n = 20) received 12 sessions, 30 minutes each, of treadmill training that increased walking speed of 10% if the participants could hold the current speed for 10 seconds. If they could not maintain the speed, then the speed was reduced by 10% in the next phase. This increase and decrease continued in the entire sessions. The LTT group (n = 20) received 12 (30-minute) sessions of a treadmill training that increased by no more than 5% of the maximum initial walking speed each week (20% over 4 weeks). The CGT (n = 20) group received 12 sessions, 45 minutes, of a physiotherapeutic gait therapy based on the principles of the proprioceptive neuromuscular facilitation and Bobath concepts. In addition, all the groups received eight sessions (45 minutes) of conventional physiotherapy.

After a 4-week training period, the STT group improved more significantly in walking speed (+1.02 m/s) than the LTT (+0.56 m/s) or CGT (+0.31 m/s) groups in the 10MWT, the fastest comfortable overground walking speed. In addition, there was a significant difference between the LTT and CGT groups. All of the three groups improved walking speed from limited community ambulation to full-community ambulation. The findings reveal that speed-dependent training modality gives greater results in walking speed; treadmill training with and without significant speed increases is also more beneficial in improving walking speed than CGT. Therefore, combining STT with physiotherapy is an efficient exercise regimen for improving walking speed in subacute stroke recovery with limited community ambulation.

These findings from the above eight RCTs provide evidence that combining treadmill exercise with conventional therapy in acute and subacute stroke recovery can produce better clinical improvements in transitions from household through limited community to full-community ambulation. In addition, repetitive and speed-dependent training provides additional walking capacity. Exercise prescription can be applied differently based on participants' ambulatory ability; however, the findings suggest a regimen of at least 20-30 minutes, 3-5 days a week, for 3-4 weeks.

Intensive Exercise to Improve Walking Ability

Duncan et al. (2003) assessed the effects of home-based exercise on subacute stroke patients with household ambulation. The experimental group (n = 44) in 90-minute sessions of intensive home-based exercise for 3 months. The components of the intervention program were range of motion and flexibility, strengthening, balance, upper extremity functional use, and endurance. The control group (n = 48) received

usual care with physical therapy or occupational therapy prescribed by their physicians and also received home visits by research staff every 2 weeks for health education, vital signs, and a test of oxygen saturation. After the training, the experimental group achieved greater gains in the 6-minute walking speed (+0.18 m/s) and walking distance (+61.61 m) compared with the control group (+0.11 m/s and +33.59 m, respectively). These results indicate that natural recovery continues in the subacute phase, and the home-based intensive exercise program could be a beneficial and cost-effective strategy to improve additional walking functions for stroke survivors discharged after acute rehabilitation.

Dual-Task Exercise to Improve Walking Ability

The concept of dual-task exercise involves the performance of two tasks at the same time and is helpful in reflecting the broader dimensions in community ambulation (Lord & Rochester, 2005). Yang, Wang, Chen, and Kao (2007) conducted a 4-week dual-task-based ball exercise study in chronic stroke survivors with full-community ambulation. The experimental group (n = 13) participated in 30 minutes of ball exercise program, three times a week, for 4 weeks. During the ball exercise, participants walked while manipulating either one or two balls (i.e., holding one or two balls in their hands). The control group (n = 12) did not receive any matched attention rehabilitation training. In this study, walking speed was measured under the single-task condition (walking) and under the dual-task condition (walking carrying a tray with glasses). The experimental group showed significant improvement in walking speed under the single-task and dual-task conditions (+29.73 and +31.08 cm/s, respectively) compared with the control group ( - 12.84 and + 12.93 cm/s, respectively). The posttest walking speed in the experimental group was 115.35 cm/s, which is enough to function as healthy senior pedestrians (1.28 m/s; Laufer et al., 2001).

On the basis of a review of the above literature, gait-oriented exercise is effective in improving walking capacity for stroke survivors in acute to chronic recovery. In addition, initiating early rehabilitation from the acute to subacute phase can produce walking transitions from household to full-community ambulation. Dual-task exercise can be a novel strategy for chronic survivors with full-community ambulation to optimize their ambulatory function.

Discussion

In this review, aerobic exercise is shown to improve balance in chronic stroke survivors. This finding refutes the results of previous systematic reviews that balance or gait-oriented trainings have a nonsignificant effect (Yeasell, Foley, Bhogal, & Speechley, 2003; van de Port et al., 2007). In addition, this review extends the body of literature on balance and falls in stroke survivors. Aerobic exercise is beneficial to improving chronic survivors' balance and, presumably, their level of activity.

Among eight RCTs that assessed balance by BBS, six reported that both the experimental and control groups showed improvements in balance, but there was no significant difference between the groups. This may be explained, in part, by the small sample sizes. Another possible explanation is the ceiling effect of measures used as participants in seven RCTs already had good balance (BBS scores of 40 or higher).

In one RCT, before the intervention, subjects were impaired in the "acceptable range" (i.e., BBS scores of 21-40, a level of balance that put them at risk for falls). The remaining RCTs examined participants who had substantively higher BBS scores, possibly precluding clinically significant improvements in balance. Further studies need to be conducted for populations with more significant balance impairment to assess the true value of the interventions tested.

There is evidence that timing plays a role in improving balance in rehabilitation. Exercise performed in the acute recovery period showed greater improvements in balance by 12-15 points in BBS within the first year of stroke compared with a BBS increase of 2-7 points in subacute or chronic recovery. This finding supports that early intervention is critical to optimize rehabilitation (Duncan et al., 2005).

Gait-oriented walking exercise has been proven to improve walking capacity for stroke survivors who are in different phases of recovery and who have variable ambulatory ability. This finding is similar to previous review results (van de Port et al., 2007). Structured STT may be beneficial in improving walking speed and distance. In addition, stroke survivors who initiated early rehabilitation with gait-oriented exercise produced greater improvements in walking ability. These findings suggest that early intervention or a specific intervention may be instrumental in upgrading walking transition from household to limited community ambulation, from limited to full-community ambulation, or from household to full-community ambulation.

Limitation

This review has several potential limitations. First, it examined balance and walking only in RCTs published in the English language. Second, in most of the studies examined, participants were exposed to several treatments; therefore, identifying pure effects of the treatment exercises was difficult. Third, some studies had small sample sizes, which limit generalizability. All of the studies reviewed lacked longitudinal follow-up data. Further longitudinal studies are needed to discern whether participants maintain their improvements over time. Finally, only a few RCTs that investigated interventions for the most profoundly affected stroke survivors with household-only ambulatory ability were found. Home-based exercise could be one strategy for this population to improve walking ability (Duncan et al., 2003).

Nursing Implications

Specific recommendations regarding exercise in the poststroke population have not been published, partly because of the variability in study methodology to date, as evidenced in this review. Another confounding element is the heterogeneity of neurological deficit profiles in stroke survivors that mandate customization of specific exercise prescriptions. However, based on the articles analyzed in this review, a regimen lasting at least 6 weeks, 1 hour per session, three to five times per week, may be recommended to improve balance and a regimen of at least 4 weeks, 20-30 minutes of gait-oriented exercise, three to five times per week, for walking are recommended for improvements in balance and walking.

Nurses play a crucial role in managing the recovery trajectory of patients poststroke. Beginning in the acute phase, the focus is on stabilization of neurological status and management of comorbid illnesses. Evidence suggests that early mobilization and therapeutic exercise is linked to better functional outcomes (Indredavik, Bakke, Slordahl, Rokseth, & Haheim, 1999). During the subacute phase of recovery, when survivors are likely to receive inpatient or outpatient rehabilitation services, the emphasis of care switches to functional recovery and development of adaptive or compensatory strategies. It is during this phase that stroke survivors and therapists can most readily capitalize on spontaneous neurological and functional recovery and initiate exercise patterns translatable to home and community settings.

Nurses in these settings have a key role in observing stroke survivors carrying out activities of daily living, identifying potential safety risks, and collaborating with physicians, physical and occupational therapists, and other rehabilitation professionals to identify an appropriate and effective plan of care. Nurses also play a crucial role in educating stroke survivors and their families on the importance of developing and maintaining good exercise habits to facilitate ambulatory recovery and reduce secondary stroke risk.

Once stroke survivors are discharged from formal rehabilitation services and resume life at home, community health nurses may assist with identifying safe places for stroke survivors and family members to exercise in the home or community setting. Furthermore, nurses should provide support and motivation for survivors to continue and progress exercise regimens for permanent incorporation into a daily routine. Community-based nurses may also be instrumental in monitoring functional abilities and triggering appropriate referrals to therapists and rehabilitation professionals to enhance recovery.

Many stroke survivors are referred to extended care settings, requiring additional rehabilitation time prior to discharge to home. Nurses in these settings that understand the importance of incorporating as much exercise as possible into a daily routine can educate and direct the patient care team accordingly. Encouragement and motivation of caring staff to continually progress activity may positively influence functional recovery and return to independence.

Conclusion

In conclusion, current literature suggests that ideal exercise intervention for stroke survivors includes a combination of gait, balance, and aerobic activities. The regimen should be customized for individual participants and appropriate to their level of impairment. Future directions in research should include longitudinal follow-up data for exercise intervention studies to examine whether participants maintain improvements over time. Further study is also needed to examine impact of exercise interventions across the spectrum of neurological deficit profiles and whether or not home-based rehabilitation focused on balance and walking is as safe and beneficial as hospital-centered rehabilitation models. Further study is needed to test and evaluate strategies to motivate chronic stroke patients to adapt and maintain exercise behavior, because current evidence indicates that exercise behavior is helpful in recovering function and independence, reducing disability and secondary complications, and preventing secondary stroke, all of which are more likely to improve quality of life.

References

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Questions or comments about this article may be directed to Minjeong An, MSN RN FNP-BC, at man001@umaryland.edu. She is a doctoral student at the University of Maryland School of Nursing, Baltimore, MD.

Marianne Shaughnessy, PhD RN CRNP, is the associate director of Education/Evaluation at the Baltimore VA Geriatric Research Education and Clinical Center (GRECC) and an associate professor at the University of Maryland School of Nursing, Baltimore, MD.

The authors declare no conflict of interest.

DOI: 10.1097/JNN.0b013e318234ea24
TABLE 1. Methodological Quality of the 17 Included Randomized
Controlled Trials

                                    PEDro Criterion Number (a)

Study                        1    2   3   4   5   6   7   8   9   10

Au-Yeung et al. (2009)       Y    1   0   1   0   0   1   0   1   1
Barbeau et al. (2003)        Y    1   0   1   0   0   1   0   0   1
Bayouk et al. (2006)         Y    1   0   1   0   0   0   1   0   0
Duncan et al. (2003)         Y    1   1   1   0   0   1   1   1   1
Franceschini et al. (2009)   Y    1   0   1   0   0   1   0   1   1
Langhammer et al. (2010)     Y    1   1   1   0   0   1   1   1   1
Langhammer et al. (2009)     Y    1   1   1   0   0   1   1   1   1
Laufer et al. (2001)         Y    0   0   1   0   0   1   1   0   1
Macko et al. (2005)          Y    1   0   1   0   0   1   0   0   1
Marigold et al. (2005)       Y    1   1   1   0   0   1   0   0   1
Noh et al. (2008)            Y    1   0   1   0   0   1   0   0   1
Pang et al. (2005)           Y    1   1   1   0   0   1   1   1   1
Peurala et al. (2009)        Y    1   1   1   0   0   0   0   0   1
Pohl et al. (2002)           Y    1   0   1   0   0   1   1   0   1
Yang et al. (2007)           Y    1   1   1   0   0   1   1   0   1
Yelnik et al. (2008)         Y    0   0   1   0   0   1   1   1   1
Yen et al. (2008)            Y    1   1   1   0   0   0   1   1   1

                             PEDro Criterion
                               Number (a)

                                  Total
Study                        11   Score

Au-Yeung et al. (2009)       1    6/10
Barbeau et al. (2003)        0    4/10
Bayouk et al. (2006)         1    4/10
Duncan et al. (2003)         1    8/10
Franceschini et al. (2009)   1    6/10
Langhammer et al. (2010)     1    8/10
Langhammer et al. (2009)     1    8/10
Laufer et al. (2001)         1    5/10
Macko et al. (2005)          1    5/10
Marigold et al. (2005)       1    6/10
Noh et al. (2008)            0    4/10
Pang et al. (2005)           1    8/10
Peurala et al. (2009)        1    5/10
Pohl et al. (2002)           1    6/10
Yang et al. (2007)           1    7/10
Yelnik et al. (2008)         1    7/10
Yen et al. (2008)            1    7/10

Note. Y = yes; 1 = eligibility criteria specified (this is not
calculated for the total score); 0 = no.

(a) = eligibility criteria specified; 2 = random allocation; 3 =
concealed allocation; 4 = groups similar at baseline; 5 = subject
blinding;  6 = therapist blinding; 7 = assessor blinding; 8 =
less than 15% dropouts; 9 = intention-to-treat analysis; 10 =
between-group statistical  comparisons; 11 = point measures and
variability data.
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Author:An, Minjeong; Shaughnessy, Marianne
Publication:Journal of Neuroscience Nursing
Article Type:Report
Geographic Code:1USA
Date:Dec 1, 2011
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