After stroke, does respiratory muscle training increase respiratory muscle strength and/or endurance? Are any benefits carried over to activity and/or participation? Does it reduce respiratory complications? Systematic review of randomised or quasi-randomised trials. Adults with respiratory muscle weakness following stroke. Respiratory muscle training aimed at increasing inspiratory and/or expiratory muscle strength. Five outcomes were of interest: respiratory muscle strength, respiratory muscle endurance, activity, participation and respiratory complications. Five trials involving 263 participants were included. The mean PEDro score was 6.4 (range 3 to 8), showing moderate methodological quality. Random-effects meta-analyses showed that respiratory muscle training increased maximal inspiratory pressure by 7 cmH2O (95% CI 1 to 14) and maximal expiratory pressure by 13 cmH2O (95% CI 1 to 25); it also decreased the risk of respiratory complications (RR 0.38, 95% CI 0.15 to 0.96) compared with no/sham respiratory intervention. Whether these effects carry over to activity and participation remains uncertain. This systematic review provided evidence that respiratory muscle training is effective after stroke. Meta-analyses based on five trials indicated that 30minutes of respiratory muscle training, five times per week, for 5 weeks can be expected to increase respiratory muscle strength in very weak individuals after stroke. In addition, respiratory muscle training is expected to reduce the risk of respiratory complications after stroke. Further studies are warranted to investigate whether the benefits are carried over to activity and participation. PROSPERO (CRD42015020683). [Menezes KKP, Nascimento LR, Ada L, Polese JC, Avelino PR, Teixeira-Salmela LF (2016) Respiratory muscle training increases respiratory muscle strength and reduces respiratory complications after stroke: a systematic review.Journal of Physiotherapy62: 138-144].

Does mechanically assisted walking increase walking speed or distance in ambulatory people with stroke compared with no intervention/non-walking intervention, or with overground walking? Systematic review with meta-analysis of randomised trials. Ambulatory adults with stroke. Mechanically assisted walking (treadmill or gait trainer) without body weight support. Walking speed measured in m/s during the 10-m Walk Test and walking distance measured in m during the 6-min Walk Test. Nine studies of treadmill training comprising 977 participants were included. Treadmill training resulted in faster walking than no intervention/non-walking intervention immediately after the intervention period (MD 0.14m/s, 95% CI 0.09 to 0.19) and this was maintained beyond the intervention period (MD -0.12m/s, 95% CI 0.08 to 0.17). It also resulted in greater walking distance immediately after the intervention period (MD 40m, 95% CI 27 to 53) and this was also maintained beyond the intervention period (MD 40m, 95% CI 24 to 55). There was no immediate, statistically significant difference between treadmill training and overground training in terms of walking speed (MD 0.05m/s, 95% CI 0.12 to 0.21) or distance (MD -6m, 95% CI -45 to 33). This systematic review provides evidence that, for people with stroke who can walk, treadmill training without body weight support results in faster walking speed and greater distance than no intervention/ non-walking intervention and the benefit is maintained beyond the training period.

After stroke, is walking training with cueing of cadence superior to walking training alone in improving walking speed, stride length, cadence and symmetry? Systematic review with meta-analysis of randomised or controlled trials. Adults who have had a stroke. Walking training with cueing of cadence. Four walking outcomes were of interest: walking speed, stride length, cadence and symmetry. This review included seven trials involving 211 participants. Because one trial caused substantial statistical heterogeneity, meta-analyses were conducted with and without this trial. Walking training with cueing of cadence improved walking speed by 0.23 m/s (95% CI 0.18 to 0.27, I(2)=0%), stride length by 0.21 m (95% CI 0.14 to 0.28, I(2)=18%), cadence by 19 steps/minute (95% CI 14 to 23, I(2)=40%), and symmetry by 15% (95% CI 3 to 26, random effects) more than walking training alone. This review provides evidence that walking training with cueing of cadence improves walking speed and stride length more than walking training alone. It may also produce benefits in terms of cadence and symmetry of walking. The evidence appears strong enough to recommend the addition of 30 minutes of cueing of cadence to walking training, four times a week for 4 weeks, in order to improve walking in moderately disabled individuals with stroke. PROSPERO (CRD42013005873).

Study Design: Systematic review with meta-analysis. Background: The addition of hip strengthening to knee strengthening for persons with patellofemoral pain has the potential to optimize treatment effects. There is a need to systematically review and pool the current evidence in this area. Objective: To examine the efficacy of hip strengthening, associated or not with knee strengthening, to increase strength, reduce pain, and improve activity in individuals with patellofemoral pain. Methods: A systematic review of randomized and/or controlled trials was performed. Participants in the reviewed studies were individuals with patellofemoral pain, and the experimental intervention was hip and knee strengthening. Outcome data related to muscle strength, pain, and activity were extracted from the eligible trials and combined in a meta-analysis. Results: The review included 14 trials involving 673 participants. Random-effects meta-analyses revealed that hip and knee strengthening decreased pain (mean difference, −3.3; 95% confidence interval [CI]: −5.6, −1.1) and improved activity (standardized mean difference, 1.4; 95% CI: 0.03, 2.8) compared to no training/placebo. In addition, hip and knee strengthening was superior to knee strengthening alone for decreasing pain (mean difference, −1.5; 95% CI: −2.3, −0.8) and improving activity (standardized mean difference, 0.7; 95% CI: 0.2, 1.3). Results were maintained beyond the intervention period. Meta-analyses showed no significant changes in strength for any of the interventions. Conclusion: Hip and knee strengthening is effective and superior to knee strengthening alone for decreasing pain and improving activity in persons with patellofemoral pain; however, these outcomes were achieved without a concurrent change in strength. Level of Evidence: Therapy, level 1a-. J Orthop Sports Phys Ther 2018;48(1):19–31. Epub 15 Oct 2017. doi:10.2519/jospt.2018.7365

To evaluate the effects of different instructions for the assessment of maximum walking speed during the ten-meter walking test with chronic stroke subjects. Participants were instructed to walk under four experimental conditions: (1) comfortable speed, (2) maximum speed (simple verbal command), (3) maximum speed (modified verbal command--"catch a bus") and (4) maximum speed (verbal command + demonstration). Participants walked three times in each condition and the mean time to cover the intermediate 10 meters of a 14-meter corridor was registered to calculate the gait speed (m/s). Repeated-measures ANOVAs, followed by planned contrasts, were employed to investigate differences between the conditions (α=5%). Means, standard deviations and 95% confidence intervals (CI) were calculated. The mean values for the four conditions were: (1) 0.74m/s; (2) 0.85 m/s; (3) 0.93 m/s; (4) 0.92 m/s, respectively, with significant differences between the conditions (F=40.9; p<0.001). Comfortable speed was significantly slower than the maximum speed, indicating that the participants were able to increase speeds when required. Significant differences were observed between the second condition with the third (p=0.002; 95%CI=-0.13 to -0.03) and the fourth conditions (p=0.004; 95%CI=-0.12 to -0.02) with no differences between the third and fourth conditions (p=1.00; 95%CI=-0.04 to 0.05). The results indicated that simple verbal commands were not sufficient to capture maximum gait speed with chronic stroke subjects. Thus, for clinical assessments and research purposes, where measurements of the maximum gait speed are necessary, modified verbal commands or demonstration strategies could be employed by physical therapists to ensure accurate information.