1. Using evidence based resources, present an argument for the role of physical
activity in the long term rehabilitation of neurological patients
StudentID- 00353901

2. Stroke isdefinedas‘rapidlydevelopedclinical signsof focal (orglobal) disturbance of cerebral
function,lastingmore than24 hours or leadingtodeath,withnoapparentcause otherthan vascular
origin’ (Ahoetal.,1980, p.114). Major impairmentsafterstroke causinglongtermdisabilityinclude
motor weakness,reducedmotorcontrol,spasticityand fatigue.Thisadverselyaffectsfunctional
mobilityandthe performance of activitiesof dailyliving(ADL) makingeverydaytasks includingsitto
standto become extremelydifficult(Ouellette etal.,2004).
Studieson stroke rehabilitation have focusedonthe effectsof resistance training(RT) on the lower
extremity(LE), showingphysical activitycanenhance recoverybyencouragingbrainreorganisation
and motorrecoveryproducinggreaterimprovementsingait,mobility,coordinationandstrength
(Cooke,Tallis,Clark,&Pomeroy,2010).Despite thisknowledgeprevious theories surroundingRT
believethatstrengtheningprogrammesincreasespasticityandpain instroke patients (Harris,&Eng,
2010). However,evidence thatmuscle tone isincreasedbystrengtheningexercisesisweak,
therefore the recommendationsfor stroke rehabilitationnow includesRT(Flansbjer,Miller,
Downham,& Lexell,2008). RT is definedas‘progressiveincreasesinresistance toa muscle as
traininginducesgreaterabilitytoproduce andsustainforce’(Kraemeretal.,2002, p.364). The
clinical guidelinesstate RTshouldbe carriedouttwotimesperweekand involve functional activities
developingdynamicbalance andcoordinationexercises (National instituteforHealthandClinical
Excellence,2013).This assignmentwill presentanargumentforthe role of RT onthe LE in the long
termrehabilitation (LTR) of stroke since the mostcommongoal statedby stroke patients is
improvedwalkingfunction(Kim, Eng,MacIntyre,&Dawson,2001). Searchstrategiesusedtolocate
randomisedcontrolledtrials(RCT) forthisassignmentinvolvedkeywordssuchasstroke,
cerebrovascularaccident,resistance trainingandstrengthtraining.Allof whichwere accessedon
databasesMedline,CINHALandCochrane andintegratedusingBooleanoperators“AND”and“OR”.
See appendix.

3. Researchpapersused inthisassignment were RCTdue tobeinghighonthe hierarchyof evidence
because theyare more likelytodemonstrate strongevidence (Evans.,2002). Studiesonthe
applicationof RTwithstroke patientsvarygreatlywithregardto duration,intensityandoutcome
measures,makingitchallengingto interpretresultsandtherefore applyto clinical practice.
Participants whometthe inclusioncriteria,inthe studieschosen, neededtobe able towalkten
metersindependently,implyingitisonlysuitablefor10-25% of the stroke population.Thismeant
that the sample size of the studiesvariedfromeachtrial. A large sample size of 102, usedby Cooke,
Tallis,Clark,&Pomeroy(2010) and 137 byMares etal.(2013) enhancesthe reliabilityand
applicationof RTintoclinical practice comparedtoLee et al.(2013) whichhad a small sample size of
28, makingitlessreliable since itdoesnotrepresentthe whole stroke population.
To developstrengthaminimumof six weeksisrequiredforphysiological changes tooccur.This was
seenbyCooke,Tallis,Clark,&Pomeroy(2010) andMares etal.(2013) whichboth demonstrateda
durationof six weeks,fourtimesaweekforanhour whichisessential tosee change.They usedthe
tenmetre walktestfor an outcome measure withthe resultsshowingasignificantincreasein
walkingspeedscomparedtothe control group.Researchshowsgoodreliabilityforthe tenmeter
walktestinstoke patients,aslongas comfortable gaitspeedsare maintained(Scivolettoetal.,
2011). It is therefore,the physiotherapist’srole to identify the importance of technique overspeed.
ThissuggeststhatRT waseffective andcontributestoimprovedgaittherefore shouldbe considered
by physiotherapistinthe LTR of stroke.However,hourlongsessionsmaybe unendurableforstroke
patientswhobecome fatiguedrapidly,whichwastakenintoaccountbyMares et al.(2013) by
includingarestperiod.Scianni,Teixeira,&Ada(2010), Yang etal. (2006), and Lee et al.(2013)
addressed thisissue by reducingsessiontimetothirtyminutesallowinggreaterparticipant
compliance andpreventingfatiguetooccur mid-session. The validityof Yangetal. (2006) is
questionable since the durationwasforfourweeks whichisn’tenoughtimeforphysiological
changesinthe musclestooccur. Statedpreviously,ittakesaminimumof six weekstosee strength
improvementswhichwas recognised byotherstudieswhichhada durationof six weeksormore.

4. PatientsselectedinCooke,Tallis,Clark,&Pomeroy(2010) and Yang et al.(2006) were volunteers
fromlocal participatinghospitals,makingthe trials susceptible tovolunteerbiasbecause the
patientshave activelypursued additionaltreatmentwhichmayhave enhancedfurtherrecovery.
Additional gainswereshown byCooke,Tallis,Clark,&Pomeroy(2010),Mares et al.(2013) and Yang
et al.(2006) whichfoundthatcombiningRTwithtask orientated,goal directedactivitiessuchassit
to stand,stair climbingandbedmobilityimprovedfunctionandindependence. RTconsistingof
balance,endurance andflexibilitywithfunctional activitieshasledtoenhancedperformanceof ADL
and therefore shouldbe integratedinto LTR(Bale,&Strand, 2008).
Scianni,Teixeira,&Ada(2010) revealedthatRTfocusingontwelve lowerlimb(LL) muscle groups
couldencourage better-qualitywalkingpatternslongtermsince weaknessof LLmuscleshasshown
to directlycorrelate withwalkingspeedandendurance (Mehtaetal.2012). Yet, improvedwalking
technique wasalsodisplayedbyYangetal. (2006) whichtargetedsix LLmuscle groups.The primary
outcome measure usedwasa handhelddynamometer.Thisinvolvedthe participantsexerting
maximal force whilstthe dynamometerwasheldstable bythe researcher.The resultsshow a
substantial improvementinstrengthinall muscle groupsafterRT.Evidence illustratesgoodvalidity
for the dynamometerbutneedsto be the same researchertakingthe measurementstostandardise
the data collection (Arnold,Warkentin,Chilibeck,&Magnus,2010). The reliabilityof boththese
studiesis uncertainsince the numberof muscle groupstargetedwerevariedandsuggestsother
trialsaffectingmultiplemuscle groups infunctional movements are neededtogetan accurate
conclusion.
Mares et al.(2013) presentedacase reportingpositivefindings withatrial on boththe LE and the
upperextremity(UE) since adequatestrengthinthe UEis directlyrelatedtothe ability toperform
ADL (Harris,& Eng, 2010). The functional ambulationcategories(FAC) testwasusedforthe LE and
the action research arm test(ARAT) wasusedforthe UE. The FAC resultsshow anincrease in
walkingability andresponsivenessinhemiplegicpatientsafterstroke, withimprovementsinstep

5. length,distance walkedandwalkingvelocity. Researchshowsgoodtest-retestreliabilityof the FAC
testand highpatientcompliance (Mehrholz,Wagner,Rutte,Meissner,&Pohl,2007). ARAT results
showedimprovementsindexterity,motorcoordinationandgrasp.ARAThas highreliabilityand
validityandisregularlyusedtomeasure motorfunctioninthe UE (Rabadi,&Rabadi,2006).
Consequently, aphysiotherapistshouldtake intoconsiderationcombiningRTof the LE and the UE
since both are affectedduringstroke leavingsurvivorswithlongtermlimbimpairments(Mareset
al.,2014). And so,by maximisingthe capacityforvoluntaryneuromuscularactivationinthe LE and
UE, patientsare more likelytobenefitfromRTinterventionsduring LTR(daSilvaetal.,2015).
ParticipantsusedbyCooke,Tallis,Clark,&Pomeroy(2010) and Mares etal. (2013) bothhad follow
upsafter the intervention.The follow upbyCooke,Tallis,Clark,&Pomeroy(2010) wasthree months
aftertreatmentwhichshowedthe benefitsgained fromRTwere maintained.Suggesting RTwasa
successful treatmentinterventionwhichfacilitatedstrokepatientsin performingADLandhelping
thembecome more independent.The follow upbyMareset al.(2013) howeverwassix monthsafter
treatmentandindicated the initialimprovementsseendeterioratedslightlyafterthe longperiod,
mostpatientscouldstill walkindependentlybutwithsome compensation. ImplyingRTiseffective
for a short periodof time howeverneedstobe continuedtoensure the benefitsare maintained in
the longterm.
Comparingthese studies itsfairtoconclude RT improvesthe functionof the LEpost-stroke,allowing
patientstoperformADLmore effectively.The durationandintensityof RTisstill uncertainsince
gainswere developedfromdifferent frequenciesanddurations.Althoughmostbenefitswereseen
instudieswhichhada durationof more than six weeksanda sessiontime of thirtyminutes,since
reducedsessiontimesfromone hourdowntothirtyminutesavoidsthe onsetof fatigue andislikely
to have highpatient adherence.CombiningRTwithtaskorientatedactivitiesalsoprovedtoshow
furtherbenefitsingaitinthe LE showingitsimportance inLTRsince itfacilitatespatient’sprogress
by givingthemafunctional task.The numberof muscle groups targetedinRT isstill uncertain

6. because strengthimprovementswere gainedfromtargetingtwelvemuscle groupsScianni,Teixeira,
Ada (2010) andin six muscle groupsYanget al.(2006). Nevertheless,Maresetal.(2013) indicated
the effectivenessof conjoiningRTof the LE withthe UE whichcouldbe usedas a development
theme forfurtherresearchers toconsidersince stroke affectsboth. WhetherRTshouldbe usedfor
the LTR of stroke is still questionable because the follow upsafterthe interventionsshow adecline
inthe initial improvementsaftersix months.Thissuggeststhatonce formal treatmenthasceased,to
maintainthe benefitsahome exerciseprogramme of functional strengthisneededtoreduce the
onsetof longterm effectsof stroke.

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9. Appendix 1.EBSCOMedline

10. Appendix 2.CINAHL

11. Appendix 3. Cochrane Library