Objective: To evaluate risk factor reduction and health-related quality of life following a 10-week cardiac rehabilitation programme in non-acute ischaemic stroke subjects. Design: Single-blinded randomized control trial. Setting: Outpatient rehabilitation. Subjects: Forty-eight community-dwelling ischaemic stroke patients (38 independently mobile, 9 requiring assistance, 1 non-ambulatory) were randomly assigned to intervention or control groups by concealed allocation. Intervention: The trial consisted of a 10-week schedule with measures taken at weeks 1 and 10. Both groups continued usual care (excluding aerobic exercise); intervention subjects attended 16 cycle ergometry sessions of aerobic-training intensity and two stress-management classes. Main outcome measures: Cardiac risk score (CRS); VO₂ (mL O₂/kg per minute) and Borg Rate of Perceived Exertion (RPE) assessed during a standardized ergometry test; Hospital Anxiety and Depression Scale (HADS); Frenchay Activity Index; Fasting Lipid Profiles and Resting Blood Pressure. Results: Group comparison with independent t-tests showed significantly greater improvement at follow-up by intervention subjects than controls in VO₂ (intervention 10.6 ±1.6 to 12.0 ± 2.2, control 11.1 ±1.8 to 11.1 ±1.9 t=4.734, P<0.001) and CRS (intervention 13.4 ±10.1 to 12.4 ±10.5, control 9.4 ±6.7 to 15.0 ±6.1 t=-2.537, P<0.05). RPE rating decreased in intervention subjects (13.4 ±12.2 to 12.4 ±2.0) and increased in controls (13.8 ±1.8 to 14.4 ±1.6); Mann—Whitney U (U = 173.5, P<0.05). Within-group comparison showed significant decrease in the HADS depression subscale in the intervention group alone (5.1 ±3.4 to 3.0 ±2.8) (Wilcoxon signed ranks test Z=-3.278, P<0.001). Conclusion: Preliminary findings suggest non-acute ischaemic stroke patients can improve their cardiovascular fitness and reduce their CRS with a cardiac rehabilitation programme. The intervention was associated with improvement in self-reported depression.

Objective Concussion symptoms normally resolve within 7–10 days but vertigo, dizziness and balance dysfunction persist in 10–30% of cases causing significant morbidity. This study systematically evaluated the evidence supporting the efficacy, prescription and progression patterns of vestibular rehabilitation therapy (VRT) in patients with concussion. Design Systematic Review, guided by PRISMA guidelines and presenting a best evidence synthesis. Data sources Electronic databases PubMed (1949 to May 2015), CINAHL (1982 to May 2015), EMBASE (1947 to May 2015), SPORTDiscus (1985 to May 2015), Web of Science (1945 to May 2015) and PEDRO (1999 to May 2015), supplemented by manual searches and grey literature. Eligibility criteria for study selection Article or abstract of original research, population of patients with concussion/mild traumatic brain injury (mTBI) with vestibular symptoms, interventions detailing VRT, measurement of outcomes pre-VRT/post-VRT. Study type was not specified. Results Following a double review of abstract and full-text articles, 10 studies met the inclusion criteria: randomised controlled trial (n=2), uncontrolled studies (n=3) and case studies (n=5). 4 studies evaluated VRT as a single intervention. 6 studies incorporated VRT in multimodal interventions (including manual therapy, strength training, occupational tasks, counselling or medication). 9 studies reported improvement in outcomes but level I evidence from only 1 study was found that demonstrated increased rates (OR 3.91; 95% CI 1.34 to 11.34; p=0.002) of medical clearance for return to sport within 8 weeks, when VRT (combined with cervical therapy) was compared with usual care. Heterogeneity in study type and outcomes precluded meta-analysis. Habituation and adaptation exercises were employed in 8 studies and balance exercises in 9 studies. Prescription and progression patterns lacked standardisation. Conclusions Current evidence for optimal prescription and efficacy of VRT in patients with mTBI/concussion is limited. Available evidence, although weak, shows promise in this population. Further high-level studies evaluating the effects of VRT in patients with mTBI/concussion with vestibular and/or balance dysfunction are required.

Purpose: Approximately 70% of strokes occur in low and middle income countries, yet the effectiveness of physical rehabilitation in these contexts remains undetermined. This systematic review identifies and summarises the current evidence supporting physical rehabilitation interventions post-stroke in low and lower-middle income countries. Methods: Five databases were comprehensively searched (April 2017) for randomised controlled trials, clinical controlled trials, and cohort studies testing rehabilitation interventions post-stroke in these countries. The Effective Public Health Practice Project Tool assessed quality of included studies. Results: Sixty-two studies (2115 participants) were included. Interventions addressed upper limb (n = 26), lower limb (n = 22), and other (n = 14) outcomes. Seven studies were rated as strong in quality, 16 moderate and 39 rated as weak. Overall, in addition to usual care, physical rehabilitation interventions improved outcomes for stroke survivors. Best evidence synthesis provides level I (b) evidence supporting constraint induced movement therapy and mirror therapy to improve upper limb functional outcomes. Level I (b) evidence supports multimodal interventions that include lower limb motor imagery to improve gait parameters. Level II (b) evidence supports sit-to-stand training to improve balance outcomes. Conclusions: Exercise-based and brain training interventions improved functional outcomes post-stroke in low and lower-middle income countries. Further high-quality studies including participation outcomes are required.

Secondary prevention in ischaemic stroke and transient ischaemic attack (TIA) is dominated by pharmacological interventions with evidence for non-pharmacological interventions being less robust. This systematic review and meta-analysis examines the impact of lifestyle interventions on secondary prevention in stroke or TIA. A systematic literature search was performed. Randomised controlled trials (RCTs) examining the effectiveness of intervention packages incorporating any key component of health education/promotion/counselling on lifestyle and/or aerobic exercise compared to usual care ± a sham intervention in participants with ischaemic stroke or TIA were included. Outcomes of interest were mortality, cardiovascular disease (CVD) event rates, cardiovascular risk factors including blood pressure, lipid profiles and physical activity participation. Methodological quality was assessed. Statistical analyses determining treatment effect were conducted using Cochrane Review Manager Software. Seventeen RCTs were included. Data pooled from eight studies with a total of 2478 patients, demonstrated no effect in favour of lifestyle interventions compared to routine or sham interventions on mortality (risk ratio (RR) = 1.13 (95% confidence interval (CI), 0.85–1.52), I²= 0%). Data relating to CVD events were pooled from four studies (1013 patients), demonstrated non-significant findings (RR = 1.16 (95% CI, 0.80--1.71), I²= 0%). Similar results were reported for total cholesterol. Physical activity participation demonstrated significant improvement [SMD 0.24 (95% CI, 0.08–0.41), l² = 47%]. Blood pressure reductions were noted but were non-significant when corrected for multimodal packages including enhanced pharmacotherapy compliance. There is currently insufficient high quality research to support lifestyle interventions post-stroke or TIA on mortality, CVD event rates and cardio-metabolic risk factor profiles. Promising blood pressure reductions were noted in multimodal interventions which addressed lifestyle.