Strength training protocols in hemiparetic individuals post stroke: a systematic review

Barbosa, Diogo Dutra; Trojahn, Mirele Ruff; Porto, Daniela Veber Gularte; Hentschke, Guilherme Scotta; Hentschke, Vítor Scotta

doi:10.1590/1980-5918.031.AO27

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REVIEW ARTICLES • Fisioter. mov. 31 • 2018 • https://doi.org/10.1590/1980-5918.031.AO27 copy

Strength training protocols in hemiparetic individuals post stroke: a systematic review

Protocolos de treinamento de força em hemiparéticos após acidente vascular cerebral: revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction:

Hemiparesis is one of the main sequels of stroke. Evidence suggests that muscle strength exercises are important in rehabilitation programs for hemiparetic patients, but wide variation in previously studied protocols makes the most suitable choice difficult in clinical practice.

Objective:

The aim of this study was to investigate strength training protocols for people with hemiparesis after stroke.

Methods:

A systematic review of literature was performed in the PubMed, PEDro (Physiotherapy Evidence Database), SciELO (Scientific Electronic Library Online), and LILACS (Latin American and Caribbean Literature in Health Science) databases. Only controlled clinical studies that contained strength training protocols for hemiparesis after stroke were selected.

Results:

In total, 562 articles were found. Of them, 12 were accepted for the systematic review. Although strength training protocols are effective in hemiparetic patients, we did not found a standard method for strength training.

Conclusion:

This systematic revision highlights the lack of a standard protocol for strength training, considering the following training parameters: volume, intensity, frequency, series, and repetitions. Isotonic exercises are most commonly used.

Keywords:
Exercise; Paresis; Muscle Strength; Stroke; Strength training

DATABASE	KEYWORDS
SciELO	(acidente vascular encefálico OR paresia OR acidente vascular cerebral OR AVC) AND (exercício OR treinamento OR força)
PubMed	(stroke OR hemipar^*) AND (“strength training” OR “resistance training”)
LILACS	(Stroke OR Paresis) AND (exercise OR resistance training)
Cochrane	(stroke OR cerebrovascular accident OR paresis) AND (exercise OR resistance training OR strength training)
PEDro	“stroke” “resistance training”

Author (year)	Groups	Type of Exercise	Training Volume	Intensity	Frequency	Outcome	Result Conclusion
1. Mi-Joung Lee, et al²⁰20 Lee MJ, Kilbreath SL, Singh MF, Zeman B, Lord SR, Raymond J, et al. Comparison of effect of aerobic cycle training and progressive resistance training on walking ability after stroke: a randomized sham exercise-controlled study. J Am Geriatr Soc. 2008;56(6):976-85. Year: 2008	ATG n = 13 STG n = 13 ATG + ST n = 14 GC n = 12	Knee extension and flexion and plantar flexion (pneumatic resistance); adductors and abductors (free weights) and dorsiflexion (isometric training).	12 weeks	50% of 1 MR After 2nd week 80% of 1MR	2 × per week	Strength (dynamometry and stair climbing test) and cardiorespiratory fitness (peak FC and peak VO2 max)	Training improved the VO2 max, climbing stairs performance, and strength of individuals with stroke.
2. Michelle M. Ouellette, et al²¹21 Ouellette MM, LeBrasseur NK, Bean JF, Phillips E, Stein J, Frontera WR, et al. High-intensity resistance training improves muscle strength, self-reported function, and disability in long-term stroke survivors. Stroke. 2004;35(6):1404-9. Year: 2004	GC n = 21 STG n = 21	Leg press (bilateral), knee extension, plantar flexion, and dorsiflexion.	12 weeks	3 sets of 8-10 repetitions 70% of 1 MR Adjusted after 15 days by a new MR test	3× per week	6mWT, stair climbing and TSL test and gait speed	ST improved strength in the paretic and non-paretic lower end after stroke and reduced functional limitations and disabilities.
3. Rodrigo Fernandez Gonzalo et al²²22 Fernandez-Gonzalo R, Fernandez-Gonzalo S, Turon M, Prieto C, Tesch PA, García-Carreira MC. Muscle, functional and cognitive adaptations after flywheel resistance training in stroke patients: a pilot randomized controlled trial. J Neuroeng Rehabil. 2016;13:37. Year: 2016	GC: n = 16 STG n = 16	Leg press unilateral (paretic member) with emphasis in eccentric contraction.	12 weeks	4 sets of 7 MR	2 × per week Recovery period of at least 48 h between sessions	Strength (load cell; TUG) and balance (Berg scale)	Muscle power, gait performance, and balance increased in the STG.
4. David J. Clark, et al²³23 Clark DJ, Patten C. Eccentric versus concentric resistance training to enhance neuromuscular activation and walking speed following stroke. Neurorehabil Neural Repair. 2013;27(4):335-44. Year: 2013	STG eccentric n =18 STG concentric n =17	Knee extension and flexion; hip abduction, plantar flexion, and dorsiflexion; and a multistage task involving the hip, knee, and ankle.	5 weeks	3-4 sets of 10 repetitions	3 × per week	Strength (isokinetic dynamometry)	The results of this study support the hypothesis that eccentric exercise is more effective than concentric exercise for neuromuscular activation in patients post-stroke.
5. Ulla-Britt Flansbjer, et al.⁵5 Flansbjer UB, Miller M, Downham D, Lexell J. Progressive resistance training after stroke: effects on muscle strength, muscle tone, gait performance and perceived participation. J Rehabil Med. 2008;40(1):42-8. Year: 2008	STG n =15 GC n = 9	Knee extension and flexion.	10 weeks	2 series of 6-8 repetitions plus 2 sets with maximum repetitions 80% 1 MR Adjusted every 2 weeks (4x during the training period)	2× per week	Strength (isokinetic dynamometry) and TUG	The strength of the paretic limb significantly increased in the STG.
6. Severinsen K, et al.²⁴24 Severinsen K, Jakobsen JK, Pedersen AR, Overgaard K, Andersen H. Effects of resistance training and aerobic training on ambulation in chronic stroke. Am J Phys Med Rehabil. 2014;93(1):29-42. Year:2014	ATG n = 13 STG n = 14 GC n = 16	Knee extension, leg press, hip extension flexion; dorsiflexion and plantar flexion.	12 weeks	3 series of 8-12 repetitions 70% - 80% of 1 MR	3 × per week	6mWT; 10mWT; V02 peak and strength (dynamometry)	Muscle strength increased after ST and was preserved after one follow-up.
7. Felipe José Aidar et al.²⁵25 Aidar FJ, Oliveira RJ, Matos DG, Mazini Filho ML, Moreira OC, Oliveira CE, et al. A Randomized Trial Investigating the Influence of Strength Training on Quality of Life in Ischemic Stroke. Top Stroke Rehabil. 2016;23(2):84-9. Year: 2016	STG n = 11 GC n = 13	Bench press, horizontal leg press, development, abdominal exercise, high pulley, and lunge squat.	12 weeks	3 sets of 8-10 repetitions with the same intensity of 3-5 (according to the OMNI scale)	3 × per week	Strength (1MR)	The results indicated an improvement in strength measures in the STG (post-stroke patients).
8. Sung Min Son, et al.²⁶26 Son SM, Park MK, Lee NK. Influence of Resistance Exercise Training to Strengthen Muscles across Multiple Joints of the Lower Limbs on Dynamic Balance Functions of Stroke Patients. J Phys Ther Sci. 2014;26(8):1267-9. Year: 2014	STG n = 14 GC n = 14	Leg press	6 weeks	3 sets of 8-10 repetitions 70% of 1 MR (loads adjusted weekly)	5 × per week	TUG, dynamic balance, and Berg scale	Significant evolution of the STG in the anteroposterior and mid-lateral oscillation distance tests, Berg scale, and TUG relative to the GC.
9.Sami S. Alabdulwahab, et al.²⁷27 Alabdulwahab SS, Ahmad F, Singh H. Effects of Functional Limb Overloading on Symmetrical Weight Bearing, Walking Speed, Perceived Mobility, and Community Participation among Patients with Chronic Stroke. Rehabil Res Pract. 2015;2015:241519. Year:2015	STG n = 10 Group Training. Guided Tasks n = 13	STG: isotonic exercises for hip flexors and extensors; knee flexors and extensors; dorsiflexors and plantar flexors. Group Training. Guided Tasks: walk with anklet with 5% of the body weight.	4 weeks	3 series of 10-15 MR	3 × per week	Scales (Cadence, SGS, FGS, WBAL e SIS)	Significant improvements are present in all evaluated aspects of both STG and training of oriented tasks. The results of the latter are more pronounced.
10. Na Kyung Lee, et al.²⁸28 Lee NK, Son SM, Nam SH, Kwon JW, Kang KW, Kim K. Effects of progressive resistance training integrated with foot and ankle compression on spatiotemporal gait parameters of individuals with stroke. J Phys Ther Sci. 2013;25(10):1235-7. Year: 2013	STG n = 14 GC n = 14	Leg press	6 weeks	3 series of 8-10 repetitions 70% of 1MR Intensity adjusted weekly through the 1 MR test.	5 × per week	Temporal and spatial parameters of gait (electric walkway system)	Increased gait speed and pacing length were present in the STG compared to pre-intervention values in the CG.
11. C. Maria Kim, et al.²⁹29 Kim CM, Eng JJ, MacIntyre DL, Dawson AS. Effects of isokinetic strength training on walking in persons with stroke: a double-blind controlled pilot study. J Stroke Cerebrovasc Dis. 2001;10(6):265-73. Year: 2002	STG n = 10 GC n = 10	Hip flexion; knee extension and flexion, dorsiflexion, and plantar flexion.	6 weeks 18 sessions	3 sets of 10 concentric maximum repetitions	3 × per week	Strength (isokinetic dynamometry), walking performance (e.g. gait velocity), and health-related quality of life	Although both groups exhibited enhanced strength after intervention, a tendency of strength improvement in the STG was observed relative to the GC.
12. Margareta Engardt,et al.³⁰30 Engardt M, Knutsson E, Jonsson M, Sternhag M. Dynamic muscle strength training in stroke patients: effects on knee extension torque, electromyographic activity, and motor function. Arch Phys Med Rehabil. 1995;76(5):419-25. Year: 1995	STG concentric n = 10 STG eccentric n = 10	Knee extension and flexion (concentric and eccentric)	6 weeks	Growing series from 1 to 15 with 10 repetitions	2 × per week	Strength (isokinetic dynamometry), EMG, weight distribution in sit and lift movements (strength platforms), and gait speed	The extensor strength of the knee increased in both groups. Regarding the strength of the healthy limb, an increase was observed only during eccentric exercise.

Author (Year)	1	2	3	4	5	6	7	8	9	10	11	PEDro Score
1. Mi-Joung Lee, et al. (2008)	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	Yes	yes	8/10
2.Michelle M. Ouellette, et al. (2002)	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes	Yes	yes	7/10
3.Rodrigo Fernandez Gonzalo et al. (2016)	Yes	Yes	No	Yes	No	No	Yes	Yes	No	Yes	Yes	6/10
4. David J. Clark, ScD et al. (2013)	Yes	Yes	No	Yes	No	No	Yes	Yes	No	Yes	Yes	6/10
5. Ulla-Britt Flansbjer, et al. (2008)	Yes	Yes	No	Yes	No	No	Yes	Yes	No	Yes	Yes	6/10
6.Severinsen K, et al. (2014)	Yes	Yes	No	Yes	No	No	No	Yes	No	Yes	Yes	5/10
7. Felipe José Aidar et al. (2016)	Yes	Yes	No	Yes	No	No	No	No	No	No	Yes	3/10
8. Sung Min Son, et al. (2014)	Yes	Yes	No	Yes	No	No	No	No	No	Yes	No	3/10
9. Sami S. Alabdulwahab, et al. (2015)	Yes	Yes	No	Yes	No	No	No	Yes	No	Yes	Yes	5/10
10. Na Kyung Lee, et al. (2013)	Yes	Yes	No	Yes	No	No	No	No	No	Yes	Yes	4/10
11. C. Maria Kim, et al. (2002)	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes	Yes	Yes	7/10
12. Margareta Engardt, et al. (1995)	Yes	Yes	No	Yes	No	No	No	Yes	No	Yes	Yes	5/10
Average (SD) PEDro Score: 5.42(1.56)/10

	Volume/time training (weeks)	Intensity (%MR)^*	Frequency (times/week)	Series (number)	Repetitions (number)^*
Average (SD)	8.58 (3.31)	75.00 (5.48)	3 (1.04)	3.30 (0.48)	10.50 (1.84)
Median (EP)	8 (0.96)	75 (2.24)	3 (0.30)	3 (0.15)	10 (0.58)
Minimum	4	70	2	3	8
Maximum	12	80	5	4	15
Type of contraction	Predominantly isotonic.
Muscle groups/proposed exercises:	MMII: knee extensors and flexors, hip flexors, plantar flexors, and dorsiflexors; MMSS: bench press.
Outcomes/measures	Dynamometry; timed up and go; six-minute walk test; stair climbing test; sit and stand up test; isokinetic strength; walking speed; peak FC; peak VO2; 1MR; quality of life; balance; scales used to monitor perception of effort; EMG; strength platform.

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