The effects of whole-body vibration therapy on bone turnover, muscle strength, motor function, and spasticity in chronic stroke: a randomized controlled trial. A systematic review of anxiety interventions in stroke and acquired brain injury: Efficacy and trial design Electroacupuncture may help motor recovery in chronic stroke survivors: a pilot study. Skeletal and body composition changes in hemiplegic patients. Functional electrical stimulation of dorsiflexor muscle: effects on dorsiflexor strength, plantarflexor spasticity, and motor recovery in stroke patients. Transcutaneous electrical stimulation on acupuncture points improves muscle function in subjects after acute stroke: a randomized controlled trial. Bone mineral density alterations in upper and lower extremities 12 months after stroke measured by peripheral quantitative computed tomography and DXA. Progressive resistance training increases strength after stroke but this may not carry over to activity: a systematic review. Impact of botulinum toxin type A on disability and carer burden due to arm spasticity after stroke: a randomised double blind placebo controlled trial Short-term effect of local muscle vibration treatment versus sham therapy on upper limb in chronic post-stroke patients: a randomized controlled trial. Effects of sit-to-stand training combined with transcutaneous electrical stimulation on spasticity, muscle strength and balance ability in patients with stroke: A randomized controlled study. Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. Reliability of elbow stretch reflex assessment in chronic post-stroke hemiparesis Isokinetic strength training of the hemiparetic knee: effects on function and spasticity. A randomized controlled trial of surface neuromuscular electrical stimulation applied early after acute stroke: effects on wrist pain, spasticity and contractures Whole body vibration and cerebral palsy: a systematic review. Feedback-controlled and programmed stretching of the ankle plantarflexors and dorsiflexors in stroke: effects of a 4-week intervention program. Physical activity, muscle function, falls and fractures Does electrical stimulation reduce spasticity after stroke? A randomized controlled study Systematic strength training as a model of therapeutic intervention. A controlled trial in postmenopausal women with osteopenia. Progressive Hemiosteoporosis on the Paretic Side and Increased Bone Mineral Density in the Nonparetic Arm the First Year after Severe Stroke
 Effects of intensive whole-body vibration training on muscle strength and balance in adults with chronic stroke: a randomized controlled pilot study. Does low-dose botulinum toxin help the recovery of arm function when given early after stroke? A phase II randomized controlled pilot study to estimate effect size
BACKGROUND Whole-body vibration ( WBV ) has been used in older adults to improve bone health and neuromuscular function , and may have potential applications for stroke patients . AIM To investigate the effects of WBV on bone turnover , leg muscle strength , motor function , and spasticity among chronic stroke patients . DESIGN R and omized controlled trial ( RCT ) . SETTING Community . POPULATION Eighty-two chronic stroke patients . METHODS The experimental group underwent exercise training with WBV stimulation for a maximum of 15 minutes , 3 days per week for 8 weeks . The controls received the same exercises without WBV . Participants were evaluated for isokinetic knee muscle strength , serum levels of bone formation and resorption markers , spasticity and motor function of the paretic leg at baseline , immediately after the 8-week training period , and 1-month follow-up . RESULTS Intention-to-treat analysis revealed no significant changes in levels of bone turnover markers and motor function of the paretic leg over time in both groups . Muscle strength outcomes showed no significant group × time interaction , with similar significant improvements found in both groups . Spasticity of the paretic knee was significantly reduced in the experimental group ( P=0.005 ) , but not in controls ( P=0.465 ) . No serious adverse events were reported . CONCLUSION The WBV protocol used in this study did not induce additional effects on bone turnover , knee muscle strength and paretic leg motor function among chronic stroke patients . WBV may have potential to modulate spasticity , but this requires further investigation . CLINICAL REHABILITATION IMPACT More study on WBV is required before it can be recommended as an adjunct treatment in rehabilitation of chronic stroke patients Objective There is little r and omized controlled trial ( RCT ) evidence to guide treatment for anxiety after stroke . We systematic ally review ed RCTs of anxiety interventions in acquired brain injury ( ABI ) conditions including stroke and traumatic brain injury ( TBI ) in order to summarize efficacy and key aspects of trial design to help guide future RCTs . Methods We search ed the Cochrane trial register , Medline , Embase , PsychInfo and CINAHL systematic ally up to August 2017 . Two independent review ers systematic ally selected studies and extracted data . We summarized the effect size , key study characteristics and sources of potential bias in trial design . Results 14 studies ( 12 stroke ; one stroke & TBI ; one TBI ) with 928 participants were included . Meta- analysis of five psychotherapy comparisons favoured intervention over control ( st and ardized mean difference ( SMD ) : − 0.41 [ − 0.79 , − 0.03 ] , I2 = 28 % ) ; Overall effect size of pharmacotherapy comparisons favoured intervention over control ( SMD : − 2.12 [ − 3.05 , − 1.18 ] , I2 = 89 % ) . One comparison of mixed pharmacotherapy and psychotherapy favoured intervention over usual care ( SMD : − 4.79 [ − 5.87 , − 3.71 ] ) . One comparison favoured  forest therapy versus urban control ( SMD : − 2.00 [ − 2.59 , − 1.41 ] ) . All positive studies carried high or unclear risk of bias . Sample sizes were small in all included studies . Conclusions There is low quality evidence to suggest that psychotherapy and pharmacotherapy may be effective interventions in the treatment of anxiety after stroke based on underpowered studies that carried high risk of bias . Large-scale well- design ed definitive trials are needed to establish whether pharmacological or psychotherapy works . Our review highlighted key considerations for investigators wishing to design high quality trials to evaluate treatments for anxiety after stroke Past studies have suggested that acupuncture may reduce spasticity in stroke survivors . We do not know , however , whether acupuncture may enhance the effect of  strength training on motor function . This study compared upper-limb motor functional improvement in chronic stroke survivors who received a combination of  acupuncture and strength training with that of subjects who received strength training alone .  A total of 10 chronic stroke patients with moderate or severe wrist muscle spasticity were recruited for this study . The study used a crossover design with a r and om order of either combined electroacupuncture and strength training or strength training alone . Each subject received one of the two types of treatment twice a week for the first 6 weeks and switched to the other for another 6 weeks . Quantitative measurements of wrist spasticity , active wrist extension range of motion , isometric wrist strength , and clinical evaluation with Fugl-Meyer ( FM ) upper-limb motor scores were conducted before and after either treatment . After the combined treatment , the quantitative spasticity level , active wrist extension range of motion ( increased by a mean of 16.3 degrees ) , and FM upper-limb motor score ( increased by a mean of 4.9 points ) changed significantly ( p < 0.01 ) but no significant changes were noted in isometric wrist strength . The strength training alone result ed in no significant changes to any measured variable . The results of the current study indicate that the combined acupuncture and strength training treatment reduced muscle spasticity and may have improved motor function for chronic stroke survivors with moderate or severe muscle spasticity Hemiplegic patients are prone to bone loss and alterations in fat and lean mass , which ultimately affect their rehabilitation status and propensity in bone fractures . The present study aim ed to evaluate body composition and bone mineral density ( BMD ) in stroke patients within 1st year post-stroke . Fifty-eight hemiplegic patients ( 36 men and 22 women ) were enrolled in this prospect i ve study . Dual-energy X-ray absorptiometry was used to assess total-body and lower-extremity BMDs ( g/cm(2 ) ) , lean mass ( g ) , and fat mass ( g ) after 3 , 6 and 12 mo of stroke that led to hemiplegia . The Modified Ashworth Scale and the functional ambulation category were used to evaluate spasticity and ambulatory category of patients , respectively . Both sexes exhibited total-body and paretic lower-limb BMD loss , fat mass gain , and lean mass waste during the 1st 12 mo poststroke , and in most cases , statistically significant differences were found between 3 and 6 mo ; however , the pattern of changes was different between males and females . Therefore , it is suggested that disability because of hemiplegia led to alterations in muscle function , which triggered skeletal and body composition changes and rendered these patients particularly prone to increased fracture risk OBJECTIVE To evaluate the therapeutic effects of Functional Electrical Stimulation ( FES ) of the tibialis anterior muscle on plantarflexor spasticity , dorsiflexor strength , voluntary ankle dorsiflexion , and lower extremity motor recovery with stroke survivors . DESIGN We conducted a prospect i ve interventional study . SETTING Rehabilitation ward , physiotherapy unit and gait analysis laboratory . PARTICIPANTS Fifty-one patients with foot drop result ing from stroke . INTERVENTION The functional electrical stimulation ( FES ) group ( n=27 ) received 20 - 30 minutes of electrical stimulation to the peroneal nerve and anterior tibial muscle of the paretic limb along with conventional rehabilitation program ( CRP ) . The control group ( n=24 ) treated with CRP only . The subjects were treated 1 hr per day , 5 days a week , for 12 weeks . MAIN OUTCOME MEASURES Plantarflexor spasticity measured by modified ashworth scale ( MAS ) , dorsiflexion strength measured by manual muscle test ( MMT ) , active/passive ankle joint dorsiflexion range of motion , and lower-extremity motor recovery by Fugl-Meyer assessment ( FMA ) scale . RESULTS After 12 weeks of treatment , there was a significant reduction in a plantarflexor spasticity by 38.3 % in the FES group and 21.2 % in control group ( P < 0.05 ) , between the beginning and end of the trial . Dorsiflexor muscle strength was increased significantly by 56.6 % and 27.7 % in the FES group and control group , respectively . Similarly , voluntary ankle dorsiflexion and lower-extremity motor function improved significantly in both the groups . No significant differences were found in the baseline measurements among groups . When compared with control group , a significant improvement ( p < 0.05 ) was measured in all assessed parameters in the FES group at post-treatment assessment , thus FES therapy has better effect on recovery process in post-stroke rehabilitation . CONCLUSIONS Therapy combining FES and conventional rehabilitation program was superior to a conventional rehabilitation program alone , in terms of reducing spasticity , improving dorsiflexor strength and lower extremity motor recovery in stroke patients OBJECTIVE To investigate whether transcutaneous electrical stimulation , when applied to acupuncture points in patients after acute stroke , decreases spasticity and /or increases muscle strength more effectively than placebo stimulation and st and ard rehabilitation . DESIGN R and omized control trial . SUBJECTS Sixty-two patients aged 70.0 ( st and ard deviation 7.4 ) years and 9.2 ( st and ard deviation 3.4 ) days post-stroke . METHODS The patients were r and omly assigned to 3 groups receiving transcutaneous electrical stimulation , placebo stimulation , or st and ard rehabilitation alone . Stimulation was applied to 4 acupuncture points in the affected lower leg for 60 min , 5 days a week for 3 weeks . Plantarflexor spasticity , ankle muscle strength , and functional mobility were measured before treatment , weekly during treatment , and at follow-up at week 8 post-stroke . RESULTS No significant difference was found in the outcome measures among groups before treatment . When compared with st and ard rehabilitation or placebo stimulation , transcutaneous electrical stimulation to acupuncture points significantly increased the percentage of patients with normal tone , increased ankle dorsiflexor strength , and decreased antagonist co-contraction ratio ( p < 0.05 ) . The patients in the transcutaneous electrical stimulation group also tended to walk 2 - 4 days earlier than the patients in the other 2 groups . CONCLUSIONS Three weeks of transcutaneous electrical stimulation to lower leg acupuncture points , given 5 times a week within 10 days post-stroke , significantly decreased ankle plantarflexor spasticity , and increased dorsiflexor strength concomitant with a decrease in antagonist co-contraction To evaluate the loss of trabecular and cortical bone mineral density ( BMD ) and geometric parameters of bone strength expressed by stress-strain index ( SSI ) in the proximal and distal forearm and the alterations of BMD in the hip of hemiplegic patient and 12 mo after stroke . Sixty-seven hemiplegic patients ( 43 men and 24 women ) with a history of single completed strokes associated with unilateral weakness were enrolled in this prospect i ve study . All patients underwent bone densitometry measurements at 3 , 6 , and 12 mo after the initial episode of stroke . Both paretic and normal forearms were examined by peripheral quantitative computed tomography ( pQCT ) at the 4 % and 20 % sites of the forearm length and both hips were examined by dual-energy X-ray absorptiometry ( DXA ) including the area of femoral neck and greater trochanter . The diagnosis of stroke was confirmed by cranial computed tomography . Motor function was assessed by the functional ambulation category ( FAC ) and spasticity by the modified Ashworth scale ( MAS ) . We found statistically significant trabecular and cortical bone density reductions during the course of our study in the forearm , which was more profound on the paretic side . Trabecular bone loss and SSI measured at 4 % of the paretic forearm in the male group represented a 12-mo decrease of 14.01 % and 28.61 % , respectively , and in the female group 9.29 % and 19.17 % , respectively . Cortical bone and SSI measured at the 20 % site of paretic forearm in the male group corresponded to a 12-mo decrease of 4.02 % and 7.43 % , respectively , and in the female group 2.59 % and 6.97 % , respectively . Paretic femoral neck and trochanter measurements in males showed a reduction of 11.76 % and 10.38 % , respectively , and in females 13.04 % and 12.6 % , respectively . A significant loss of BMD and bone strength was found during the first year after stroke in both trabecular and cortical bone at the forearm and at the neck and great trochanter on the paretic hip . Most prominent BMD reduction was evident in men compared with perimenopausal women in the same age QUESTION Does progressive resistance training improve strength and activity after stroke ? Does any increase in strength carry over to activity ? DESIGN Systematic review of r and omised trials with meta- analysis . PARTICIPANTS Adults who have had a stroke . INTERVENTION Progressive resistance training compared with no intervention or placebo . OUTCOME MEASURES The primary outcome was change in strength . This measurement had to be of maximum voluntary force production and performed in muscles congruent with the muscles trained in the intervention . The secondary outcome was change in activity . This measurement had to be a direct measure of performance that produced continuous or ordinal data , or with scales that produced ordinal data . RESULTS Eleven studies involving 370 participants were included in this systematic review . The overall effect of progressive resistance training on strength was examined by pooling change scores from six studies with a mean PEDro score of 5.8 , representing medium quality . The effect size of  progressive resistance training on strength was 0.98 ( 95 % CI 0.67 to 1.29 , I2=0 % ) . The overall effect of progressive resistance training on activity was examined by pooling change scores from the same six studies . The effect size of progressive resistance training on activity was 0.42 ( 95 % CI -0.08 to 0.91 , I2=54 % ) . CONCLUSION After stroke , progressive resistance training has a large effect on strength compared with no intervention or placebo . There is uncertainty about whether these large increases in strength carry over to improvements in activity . REVIEW REGISTRATION PROSPERO CRD42015025401 . [ Dorsch S , Ada L , Alloggia D ( 2018 ) Progressive resistance training increases strength after stroke but this may not carry over to activity : a systematic review . Journal of Physiotherapy 64 : 84 - 90 ] OBJECTIVES After stroke , abnormal arm posture due to spasticity in a functionally useless arm may interfere with self care tasks . In these patients botulinum toxin treatment presents an opportunity to reduce disability . The purpose was to investigate whether reduction in spasticity after botulinum toxin treatment translates into reduction in disability and carer burden . METHODS Forty patients with stroke with spasticity in a functionally useless arm ( median duration 3.1 years ) were r and omised to receive  intramuscular botulinum toxin type A ( BT-A ; Dysport ) ( n=20 ) or placebo ( n=20 ) in a total dose of 1000 MU divided between elbow , wrist , and finger flexors . Spasticity ( using the modified Ashworth scale ) , muscle power , joint movement , and pain were assessed . Disability and carer burden were measured using an eight item and a four item scale respectively . Two baseline and three post-treatment assessment s ( weeks 2 , 6 , and 12 ) were made . Concurrent treatments as far as possible remained unchanged and not optimised . RESULTS Disability improved at week 6 with BT-A compared with placebo . This effect , present at week 2 , wore off by week 12 . Reduction in carer burden was seen at week 6 with BT-A and continued for at least 12 weeks . Forearm flexor spasticity was reduced with BT-A up to 12 weeks after treatment . Although significant improvement in elbow flexor spasticity was seen at week 2 with BT-A compared with placebo , this effect was not evident at weeks 6 and 12 . Arm pain was not improved after BT-A. Grip strength was reduced with BT-A. No serious BT-A related adverse effects were reported . CONCLUSION BT-A is useful for treating patients with stroke who have self care difficulties due to arm spasticity . The decision to treat should also include relief of carer burden . As muscle weakness may occur , its potential impact on functional activities must be assessed before intervention BACKGROUND In recent years , local muscle vibration received considerable attention as a useful method for muscle stimulation in clinical therapy . Some studies described specific vibration training protocol , and few of them were conducted on post-stroke patients . Therefore there is a general uncertainty regarding the vibrations protocol . AIM The aim of this study was to evaluate the effects of local muscle high frequency mechano-acoustic vibratory treatment on grip muscle strength , muscle tonus , disability and pain in post-stroke individuals with upper limb spasticity . DESIGN Single-blind r and omized controlled trial . SETTING Outpatient rehabilitation center . POPULATION Thirty-two chronic poststroke patients with upper-limb spasticity : 21 males , 11 females , mean age 61.59 years ±15.50 , time passed from stroke 37.78±17.72 months . METHODS The protocol treatment consisted of the application of local muscle vibration , set to a frequency of 300 Hz , for 30 minutes 3 times per week , for 12 sessions , applied to the skin covering the venter of triceps brachii and extensor carpi radialis longus and brevis muscles during voluntary isometric contraction . All participants were r and omized in two groups : group A treated with vibration protocol ; group B with sham therapy . All participants were evaluated before and after 4-week treatment with H and Grip Strength Test , Modified Ashworth Scale , QuickDASH score , FIM scale , Fugl-Meyer Assessment , Jebsen-Taylor H and Function Test and Verbal Numerical Rating Scale of pain . Outcomes between groups was compared using a repeated- measures ANOVA . RESULTS Over 4 weeks , the values recorded in group A when compared to group B demonstrated statistically significant improvement in grip muscle strength , pain and quality of life and decrease of spasticity ; P-values were < 0.05 in all tested parameters . CONCLUSIONS Rehabilitation treatment with local muscle high frequency ( 300 Hz ) vibration for 30 minutes , 3 times a week for 4 weeks , could significantly improve muscle strength and decrease muscle tonus , disability and pain in upper limb of hemiplegic post-stroke patients . CLINICAL REHABILITATION IMPACT Local muscle vibration treatment might be an additional and safe tool in the management of chronic poststroke patients , granted its high therapeutic efficiency , limited cost and short and repeatable protocol of use Sit-to-st and is a fundamental movement of human being for performing mobility and independent activity . However , Stroke people symptoms experience difficulty in conducting the sit-to-st and due to paralysis and especially ankle spasticity . Recently , transcutaneouselectrical- stimulation ( TENS ) is used to reduce pain but also to manage spasticity . The purpose of this study was to determine ( 1 ) whether TENS would lead to ankle spasticity reduction and ( 2 ) whether sit-to-st and training combined with TENS would improve spasticity , muscle strength and balance ability in stroke patients . Forty-stroke patients were recruited and were r and omly divided into two groups : TENS group ( n=20 ) and sham group ( n=20 ) . All participants underwent 30-sessions of sit-to-st and training ( for 15-min , five-times per week for 6-weeks ) . Prior to each training session , 30-min of TENS over the peroneal nerve was given in TENS group , whereas sham group received non-electrically stimulated TENS for the same amount of time . Composite-Spasticity-Score was used to assess spasticity level of ankle plantar-flexors . Isometric strength in the extensor of hip , knee and ankle were measured by h and held dynamometer . Postural-sway distance was measured using a force platform . The spasticity score in the TENS group ( 2.6±0.8 ) improved significantly greater than the sham group ( 0.7±0.8 , p<0.05 ) . The muscle strength of hip extensor in the TENS group ( 2.7±1.1 kg ) was significantly higher than the sham group ( 1.0±0.8 kg , p<0.05 ) . Significant improvement in postural-sway was observed in the TENS group compared to the sham group ( p<0.05 ) . Thus , sit-to-st and training combined with TENS may be used to improve the spasticity , balance function and muscle strength in stroke patients BACKGROUND Multiple sclerosis ( MS ) is a major cause of chronic , neurological disability , with a significant long-term disability burden , often requiring comprehensive rehabilitation . OBJECTIVES To systematic ally evaluate evidence from published Cochrane Review s of clinical trials to summarise the evidence regarding the effectiveness and safety of rehabilitation interventions for people with MS ( pwMS ) , to improve patient outcomes , and to highlight current gaps in knowledge . METHODS We search ed the Cochrane Data base of Systematic Review s up to December 2017 , to identify Cochrane Review s that assessed the effectiveness of organised rehabilitation interventions for pwMS . Two review ers independently assessed the quality of included review s , using the Revised Assessment of Multiple Systematic Review s ( R-AMSTAR ) tool , and the quality of the evidence for reported outcomes , using the GRADE framework . MAIN RESULTS Overall , we included 15 review s published in the Cochrane Library , comprising 164 r and omised controlled trials ( RCTs ) and four controlled clinical trials , with a total of 10,396 participants . The included review s evaluated a wide range of rehabilitation interventions , including : physical activity and exercise therapy , hyperbaric oxygen therapy ( HBOT ) , whole-body vibration , occupational therapy , cognitive and psychological interventions , nutritional and dietary supplements , vocational rehabilitation , information provision , telerehabilitation , and interventions for the management of spasticity . We assessed all review s to be of high to moderate method ological quality , based on R-AMSTAR criteria .Moderate- quality evidence suggested that physical therapeutic modalities ( exercise and physical activities ) improved functional outcomes ( mobility , muscular strength ) , reduced impairment ( fatigue ) , and improved participation ( quality of life ) . Moderate- quality evidence suggested that inpatient or outpatient multidisciplinary rehabilitation programmes led to longer-term gains at the levels of activity and participation , and interventions that provided information improved patient knowledge . Low-qualitty evidence suggested that neuropsychological interventions , symptom-management programmes ( spasticity ) , whole body vibration , and telerehabilitation improved some patient outcomes . Evidence for other rehabilitation modalities was inconclusive , due to lack of robust studies . AUTHORS ' CONCLUSIONS The evidence suggests that regular specialist evaluation and follow-up to assess the needs of patients with all types of MS for appropriate rehabilitation interventions may be of benefit , although the certainty of evidence varies across the different types of interventions evaluated by the review s. Structured , multidisciplinary rehabilitation programmes and physical therapy ( exercise or physical activities ) can improve functional outcomes ( mobility , muscle strength , aerobic capacity ) , and quality of life . Overall , the evidence for many rehabilitation interventions should be interpreted cautiously , as the majority of included review s did not include data from current studies . More studies , with appropriate design , which report the type and intensity of modalities and their cost-effectiveness are needed to address the current gaps in knowledge OBJECTIVE To establish reliability of quantitative measures of elbow joint spastic hypertonia in post-stroke hemiparesis . METHODS Nine subjects with post-stroke hemiparesis ( mn duration : 42 months ) were tested on three separate days . Biceps brachii and brachioradialis EMG were recorded during passive ramp- and -hold extensions applied at seven speeds between 30 and 210 degrees /s . EMG burst duration , onset position threshold , and burst intensity were used to evaluate reflex activity . Torque at 40 degrees of elbow flexion was used as a mechanical indicator of spastic hypertonia . RESULTS Across speeds ICCs were consistent , means ranged between 0.63 and 0.85 . Thus , relative reliability was fair to excellent for all parameters . Absolute reliability , determined using st and ard error of measurement expressed as a percentage of the mean score ( % SEM ) , improved at higher speeds ( > or = 120 degrees/s ) . CONCLUSIONS These results establish reliability of reflex and mechanical measures of elbow spastic hypertonia post-stroke . The data demonstrate greater reflex detection at high speeds , indicating greater potential to document meaningful changes in these distinct aspects of spastic hypertonia following intervention . SIGNIFICANCE Based on findings of this study , reliability was demonstrated using four parameters of reflex EMG and torque indicating measurement consistency across sessions . These observations motivate determination of requisite effect sizes for clinical trials that evaluate treatment outcome PURPOSE To determine whether isokinetic training can improve the strength of the hemiparetic knee musculature , functional mobility , and physical activity and to evaluate its effect on spasticity in long-term stroke survivors . DESIGN Nonr and omized self-controlled trial . SUBJECTS A volunteer sample of 15 community-dwelling stroke survivors of at least 6 months . INTERVENTION A 6-week ( 3 days/week , 40 minutes/day ) program consisting of warm-up , stretches , reciprocal knee extension and flexion isokinetic strengthening , and cool-down for the paretic limb . MAIN OUTCOME MEASURES Peak isokinetic hamstring and quadriceps torque , quadriceps spasticity , gait velocity , timed Up and Go , timed stair climb , and the Human Activity Profile ( HAP ) scores were recorded at baseline , after training , and 4 weeks after training cessation ( follow-up ) . RESULTS Paretic muscle strength improved after training ( p < .05 ) while tone remained consistent ( p > .87 ) . Gait velocity increased after training ( p < .05 ) and at follow-up ( p < .05 ) . Changes in stair climbing and timed Up and Go were not significant ( p > .37 ; p > .91 ) , although subjects perceived gains in their physical abilities at follow-up ( p < .01 ) . CONCLUSIONS Gains in strength and gait velocity without concomitant increases in muscle tone are possible after a short-term strengthening program for stroke survivors . The psychological benefit associated with physical activity is significant Objectives : To investigate effects of surface neuromuscular electrical stimulation applied early after stroke to the wrist and finger extensor muscles on upper limb pain , spasticity and contractures in patients with no functional arm movement . Design : Secondary analysis from a Phase II , r and omized , controlled , single-blind study . Setting : An acute hospital stroke unit . Subjects : Patients with no useful arm function within six weeks of a first stroke . Intervention : Patients were r and omized to treatment ( 30-minute sessions of surface neuromuscular stimulation to wrist and finger extensors and 45 minutes of physiotherapy ) or control ( 45 minutes of physiotherapy ) groups . All patients had access to routine care . Treatment was given for six weeks from recruitment . Results : Ninety patients ( 49 % male , median age 74 years ( range 32–98 ) , median time since stroke onset three weeks ( range one to six weeks ) ) were included . Treatment compliance was variable ( mean 28 % ) . The treatment prevented the development of pain ( mean difference in rate of change 0.4 units/week , 95 % confidence interval ( CI ) 0.09 to 0.6 ) . Treatment may have prevented a deterioration in contractures ( quantified by measuring passive range of movement ) in severely disabled patients ( mean rate of deterioration −0.5 deg/week ; 95 % CI −0.9 to −0.06 ) . There were no significant changes in stiffness and spasticity . Conclusion : Surface neuromuscular electrical stimulation  reduces pain in stroke patients with a non-functional arm . There was some evidence that treatment with electrical stimulation was beneficial in reducing contractures . Treatment had no effect on spasticity PURPOSE The goal of this review is to evaluate the effects of whole body vibration on outcomes in patients with cerebral palsy . The findings in this review may help clinicians make evidence informed decisions on the use of whole body vibration for cerebral palsy . METHODS A systematic search was conducted on April 29 , 2014.The following search terms were used to search of several data bases : ( whole body vibration OR whole-body vibration OR whole body-vibration OR WBV ) AND ( cerebral palsy ) . Articles that met the inclusion criteria were assessed using the Scottish intercollegiate guidelines network ( SIGN ) rating system to assess the methodology and bias of the articles for r and omized control trials . RESULTS The search produced 25 articles , of which 12 duplicates were identified and removed . Another seven articles were not considered since they did not fit the inclusion criteria , leaving a total of five studies for review . Four of the articles analyzed the effects of WBV in children while the other study focused on adults with cerebral palsy . There was one low quality article , four acceptable quality articles and one high quality article when assessed using the SIGN criteria . CONCLUSIONS It appears that whole body vibration has the potential to provide symptomatic relief for patients with cerebral palsy . Whole body vibration may improve spasticity , muscle strength and coordination . There is a lack of research to conclusively determine whether it does alter bone mineral density OBJECTIVE To investigate the effect of repeated feedback-controlled and programmed " intelligent " stretching of the ankle plantar- and dorsiflexors to treat subjects with ankle spasticity and /or contracture in stroke . DESIGN Noncontrolled trial . SETTING Institutional research center . PARTICIPANTS Subjects with spasticity and /or contracture after stroke . INTERVENTIONS Stretching of the plantar- and dorsiflexors of the ankle 3 times a week for 45 minutes during a 4-week period by using a feedback-controlled and programmed stretching device . MAIN OUTCOME MEASURES Passive and active range of motion ( ROM ) , muscle strength , joint stiffness , joint viscous damping , reflex excitability , comfortable walking speed , and subjective experiences of the subjects . RESULTS Significant improvements were found in the passive ROM , maximum voluntary contraction , ankle stiffness , and comfortable walking speed . The visual analog scales indicated very positive subjective evaluation in terms of the comfort of stretching and the effect on their involved ankle . CONCLUSIONS Repeated feedback-controlled or intelligent stretching had a positive influence on the joint properties of the ankle with spasticity and /or contracture after stroke . The stretching device may be an effective and safe alternative to manual passive motion treatment by a therapist and has potential to be used to repeatedly and regularly stretch the ankle of subjects with spasticity and /or contracture without daily involvement of clinicians or physical therapists Study design A thematic review . Objectives To evaluate if physical activity enhances muscle strength , improves balance , and reduces the fall frequency and the fracture incidence .  Background One of the major medical problems of today is the increasing incidence of fragility fractures .  Muscle strength and fall is one of the major determinants of a fracture . If physical activity could increase muscle strength , improve balance and reduce the fall frequency , then training could be recommended as prevention for fractures . Methods The review used Medline ( Pub Med ) and the search words exercise , physical activity , muscle strength , balance , falls , fractures . R and omized controlled trials ( RCT ) were predominantly included , although this not is a systematic review . Results The evidence that physical activity modifies the risk factors for fall is compelling , although RCT with fractures as end point are lacking . Physical activity is associated with improved muscle strength , co-ordination and balance .  Physical training increases muscle strength also in octogenarians by up to 200 % , i.e. a much more pronounced effect than the corresponding increase in muscle volume or bone mass . There is also evidence that physical activity decreases the actual number of falls . Observational cohort and case-control studies imply that physical activity is associated with reduced hip fracture risk . If exercise reduces the number of vertebral fractures and other fragility fractures are less evaluated . Conclusions Physical activity in older ages can be recommended to improve muscle strength and balance , to reduce the risk to fall and fractures , although the highest level of evidence – RCT with fracture as endpoint – is lacking Objective : To investigate the therapeutic effect of electrical stimulation on plantarflexor spasticity in stroke patients . Design : A r and omized controlled clinical trial study . Setting : Rehabilitation clinic of Semnan University of Medical Sciences . Subjects : Forty stroke patients ( aged from 42 to 65 years ) with ankle plantarflexor spasticity . Intervention : Fifteen minutes of inhibitory Bobath techniques were applied to one experimental group and a combination of 9 minutes of electrical stimulation on the dorsiflexor muscles and inhibitory Bobath techniques was applied to another group for 20 sessions daily . Main measures : Passive ankle joint dorsiflexion range of motion , dorsiflexion strength test , plantarflexor muscle tone by Modified Ashworth Scale and soleus muscle H-reflex . Results : The mean change of passive ankle joint dorsiflexion in the combination therapy group was 11.4 ( SD 4.79 ) degrees versus 6.1 ( SD 3.09 ) degrees , which was significantly higher ( P = 0.001 ) . The mean change of plantarflexor muscle tonicity measured by the Modified Ashworth Scale in the combination therapy group was -1.6 ( SD 0.5 ) versus -1.1 ( SD 0.31 ) in the Bobath group ( P = 0.001 ) . Dorsiflexor muscle strength was also increased significantly ( P = 0.04 ) in the combination therapy group ( 0.7 ± 0.37 ) compared with the Bobath group ( 0.4 ± 0.23 ) . However , no significant change in the amplitude of H-reflex was found between combination therapy ( -0.41 ± 0.29 ) and Bobath ( -0.3 ± 0.28 ) groups . Conclusion : Therapy combining Bobath inhibitory technique and electrical stimulation may help to reduce spasticity effectively in stroke patients Physical exercise is often recommended as a therapeutic tool to combat pre- and postmenopausal loss of bone density . However , the relationship between training dosage ( intensity , duration , frequency ) and the effect on bone density still is undergoing discussion . Furthermore , the exercise quantification programs are often described so inadequately that they are neither quantitatively nor qualitatively reproducible . The aim of this investigation was to determine whether a clearly defined training of muscle strength , under defined safety aspects , performed only twice weekly , can counteract bone density loss in women with postmenopausal osteopenia . Data from 16 women in the training group ( age , 63.6 + /- 6.2 yr ) and 15 women in the control group ( age , 67.4 + /-9.7 yr ) , of comparable height and weight , were evaluated .  Strength training was performed for 6 mo as continually adapted strength training , providing an intensity of about 70 % of each test person 's one repetition maximum . Bone mineral density of lumbar vertebrae 2 to 4 and the femoral neck was measured by dual-energy x-ray absorptiometry . Maximum performance in watts and parameters of hemodynamics were controlled with a bicycle ergometer test to maximal effort . In addition , metabolic data were assessed . In the lumbar spine and femoral neck , the training group showed no significant changes , whereas the control group demonstrated a significant loss of bone mineral density , especially in the femoral neck ( P<0.05 ) . The strength increase was highly significant in all exercised muscle groups , rising to about 70 % above the pretraining status ( P<0.001 ) . Heart rate and blood pressure data indicated a slight economization , metabolism was not significantly influenced . Based on these findings , we conclude that continually adapted strength training is an effective , safe , reproducible , and adaptable method of therapeutic strength training , following only two exercise sessions per week Abstract : Fractures are a common and serious complication after stroke and the risk of hip fractures among stroke patients is 2 to 4 times greater than among other elderly people . The aim of this study was to investigate prospect ively the change in bone mineral density ( BMD ) after severe stroke and to study the association between motor impairment , disability and the development of hemiosteoporosis . The study comprised 24 stroke patients , with no persistent paresis from previous strokes or previous osteoporotic fractures , included 1 month after stroke onset .  BMD , motor function , ambulation and activities of daily living ( ADL )  were assessed at 1 , 4 , 7 and 12 months after stroke onset . At inclusion , the patients ’ BMD was normal for their age . During the study , there was a significant loss of BMD in the total body ( −2.0 % ; p<0.05 ) , but not in the head or spine . BMD differed significantly between the paretic and the non-paretic arm at inclusion ( −4.8 % ; p<0.001 ) . Decrease in BMD was most pronounced in the affected humerus ( −17.4 % ; p<0.001 ) and proximal femur ( −12.2 % ; p<0.01 ) . BMD decreased significantly in both lower extremities during follow-up , but the losses were more pronounced on the paretic side ( p<0.01 ) . In the nonaffected ultradistal radius there was a significant increase in BMD from inclusion to the end of the study ( + 5.8 % ; p<0.01 ) . There was no pattern in the bone losses correlating with presumptive risk factors for hemiosteoporosis such as motor function , ability to perform ADL or ambulation . Two patients had fractures at follow-up , both on the paretic side . Loss of bone mineral density in the paretic extremities is thus pronounced and progressive during the first year after stroke , indicating that loss of BMD is probably an important risk factor for post-stroke fractures . Surprisingly , BMD in the nonaffected arm increased significantly during the first year after stroke , most likely due to increased physical activity , and perhaps a redistribution of bone minerals from the paretic extremities OBJECTIVES To investigate the effects of a 6-week whole body vibration ( WBV ) training program in patients with chronic stroke . DESIGN R and omized controlled pilot trial with 6 weeks ' follow-up . SETTING University hospital . PARTICIPANTS Adults with chronic stroke ( N=15 ) were r and omly assigned to an intervention ( n=7 ) or a control group ( n=8 ) . INTERVENTIONS Supervised , intensive WBV training . The vibration group performed a variety of static and dynamic squat exercises on a vibration platform with vibration amplitudes of 1.7 and 2.5 mm and frequencies of 35 and 40Hz . The vibration lasted 30 to 60 seconds , with 5 to 17 repetitions per exercise 3 times weekly for 6 weeks . Participants in the control group continued their usual activities and were not involved in any additional training program . MAIN OUTCOME MEASURES The primary outcome variable was the isometric and isokinetic muscle strength of the quadriceps ( isokinetic dynamometer ) . Additionally , hamstrings muscle strength , static and dynamic postural control ( dynamic posturography ) , and muscle spasticity ( Ashworth Scale ) were assessed . RESULTS Compliance with the vibration intervention was excellent , and the participants completed all 18 training sessions . Vibration frequencies of both 35 and 40Hz were well tolerated by the patients , and no adverse effects result ing from the vibration were noted . Overall , the effect of intensive WBV intervention result ed in significant between-group differences in favor of the vibration group only in isometric knee extension strength ( knee angle , 60 ° ) ( P=.022 ) after 6 weeks of intervention and in isokinetic knee extension strength ( velocity , 240 ° /s ) after a 6-week follow-up period ( P=.005 ) , both for the paretic leg . Postural control improved after 6 weeks of vibration in the intervention group when the patients had normal vision and a sway-referenced support surface ( P<.05 ) . Muscle spasticity was not affected by vibration ( P>.05 ) . CONCLUSIONS These preliminary results suggest that intensive WBV might potentially be a safe and feasible way to increase some aspect of lower limb muscle strength and postural control in adults with chronic stroke . Further studies should focus on evaluating how the training protocol should be administered to achieve the best possible outcome , as well as comparing this training protocol to other interventions Objective : Spasticity after stroke may be associated with worse functional outcome . Our study aim is to establish whether a low dose of botulinum toxin , given early post stroke before clinical ly evident spasticity warrants treatment , will improve recovery of arm function . Design : A double-blind r and omized placebo-controlled trial . Setting : An acute stroke unit . Subjects : Individuals recruited within three weeks of stroke onset with severe arm function deficits . Interventions : Injections of quarter and half st and ard dose botulinum toxin A to the upper limb , with a control of normal saline injections . Main measures : Arm function , active and passive movement , and spasticity at elbow and wrist were recorded at baseline , and at 4 , 8 , 12 and 20 weeks post intervention . A pre-planned subgroup analysis included only subjects with no arm function at baseline ( Action Research Arm Test score = 0 ) . Results : Thirty subjects were recruited , and 21 completed all assessment s. Arm function scores improved in all three groups between baseline and week 20 . There was no benefit for active treatment over control in the whole group analysis . In the subgroup analysis the active groups improved when compared with the control group and effect sizes for improvement in this subgroup were 0.6 and 0.5 for the quarter dose and half dose groups respectively . Conclusions : Individuals with no arm function within three weeks of stroke may benefit functionally from botulinum toxin . Using the effect size of 0.5 , further studies would need a minimum of 101 participants in each group to confirm this finding
In subacute and chronic stroke studies , the skeletal sites in the paretic limbs sustained a more pronounced decline in bone quality than did their counterparts in the non-paretic limbs .
The rate of changes showed a decelerating trend as post-stroke duration increased , but the timing of achieving the steady rate differed across skeletal sites .
The magnitude of bone changes in the paretic upper limb was more pronounced than the paretic lower limb .
There was a strong relationship between muscle strength/mass and bone density/strength index .
Muscle spasticity seemed to have a negative impact on bone integrity in the paretic upper limb , but its influence on bone properties in the paretic lower limb was uncertain .
Substantial bone changes in the paretic limbs occurred particularly in the first few months after stroke onset .
Early intervention , muscle strength training , and long-term management strategies may be important to enhance bone health post-stroke .
To systematic ally review available evidence related to the characteristics of bone changes  post-stroke and the relationship between various aspects of muscle function ( e.g. , strength , spasticity ) and bone properties after stroke onset .