on October 7, 2004
Published online before print October 7, 2004, doi: 10.1161/01.STR.0000143153.76460.7d
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Submitted on April 19, 2004
From the Department of Physical Therapy and Research Institute for Fundamental and Clinical Human Movement Sciences (G.K., R.v.P.), VU University Medical Center, Amsterdam, the Netherlands; the Center of Excellence for Rehabilitation Medicine "De Hoogstraat" (G.K.), Rudolf Magnus Institute of Neuroscience, University Medical Centre Utrecht, the Netherlands; the Department of Rehabilitation Sciences and Center for Neurorehabilitation (R.C.W.), Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, Mass; the Department of Epidemiology and Biostatistics (S.W.D.), School of Physical and Occupational Therapy, McGill University, Montreal, Quebec; the Department of Rehabilitation and Centre for Interdisciplinary Research in Rehabilitation and Social Integration (C.R.), Laval University, Quebec City, Quebec; the School of Health Professions and Rehabilitation Sciences (A.A.), University of Southampton, UK; the School for Physiotherapy (K.M.), University of Melbourne, Australia; the School of Psychology (N.L.), University of Nottingham, UK; the Centre for Health Services Studies (C.P.), University of Kent at Canterbury, UK; and the Academic Section of Geriatric Medicine (I.W., P.L.), Royal Infirmary, Glasgow, Scotland. * To whom correspondence should be addressed. E-mail: g.kwakkel{at}vumc.nl.
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.
Revised on July 23, 2004
Accepted on August 3, 2004
Effects of Augmented Exercise Therapy Time After Stroke. A Meta-Analysis
Gert Kwakkel PhD, PT*;
Key words: activities of daily living • cerebrovascular disorders • exercise • meta-analysis • occupational therapy • physical therapy • rehabilitation
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