JOURNAL PRESENTATION

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 Details of the Journal Article

Strength Training of the Non-hemiplegic Side Promotes

Motor Function Recovery in Patients with Stroke:
A Randomized Controlled Trial

Author: Chenlan Shao, Yongzheng Wang, Hui Gou,

Hua Xiao, Tingting Chen

Year of publication: October 13, 2023

Citation: Shao C, Wang Y, Gou H, Xiao H, Chen T. Strength training

of the non-hemiplegic side promotes motor function recovery in
patients with stroke: A randomized controlled trial. Archives of
Physical Medicine and Rehabilitation 2023;104: 188−94.

Peer Reviewed and Original Article

 Details of the Journal

Journal: Archives of Physical Medicine and Rehabilitation

Publisher: Elsevier Inc.

Impact Factor: 4.3

Indexed: SCOPUS

Access: This is an open access article, with the website ID as

https://doi.org/10.1016/j.apmr.2022.09.012
 Search Strategy

Search Engine: PubMed & Google Scholar

Key words: Stroke, Motor Recovery, Strength Training

1. Recent (within 5 years)

2. Original article
3. Indexing Details
4. Peer Reviewed

Article selected for the presentation

(Circulated to the PG Classmates and Evaluators on
10/11/2023 after the Moderator’s Approval)
 Justification for Article Selection

This article was very recently published and focussed on

the strength training of non-hemiplegic side (NHS) in
contrary to the training of hemiplegic side (HS) which
raised the quotient of doubt to know more about this
research.

As all current approaches are focussing on the

physiotherapeutic training of the hemiplegic side, this
research article was aimed to investigate the effect of
strength training on the unaffected side and thereby
promote balance, mobility and muscle strength of stroke
patients.
 Introduction
 Stroke is a common cause of disability, which induces a
marked decline in activities of daily life (ADL) and social
participation. Motor function recovery is a major
rehabilitation target for patients with stroke. Stroke not
only paralyzes the affected side but also reduces muscle
strength of the contralateral side.

 This decline in muscle strength on the non-hemiplegic side

must not be ignored in patients with stroke, because it is
highly associated with functional performance, and it can
be used as an independent predictor of short-term
functional gain and outcomes after stroke.

 Previous studies revealed that NHS strength training

improves muscle strength of the HS in patients with stroke.
This procedure of strength transfer, also called cross
training, is generally attributed to neural adaptations.
 Objectives of the Study

 To observe the effect of strength training of the non-

hemiplegic side (NHS) on balance function, mobility,
and muscle strength of patients with stroke.

Alternate Hypothesis of the Study

 Strength training of the non-hemiplegic side (NHS)

will improve the balance function, mobility, and
muscle strength of patients with stroke.
 Appraisal of Literature Review Studies

 No. of Articles Referred : 39

 No. of Articles in the recent 5 years (since 2018) : 15
 No. of Articles within 5-10 years (since 2013) : 13
 No. of Articles more than 10 years (since 1973) : 10
 No. of Articles Referred for Introduction : 12
 No. of Articles Referred for Methodology : 05
 No. of Articles Referred for Discussion : 22
 Findings of Literature Review

Reference No. Literature Review - Findings

Intro: 1-3 Definition of Stroke & its major problems; paralysis of
affected side
Intro: 4-7 Specific problems of stroke patients like muscle strength,
functional performance
Intro: 8-12 Strength training of non-hemiplegic side improves muscle
strength of affected side in stroke patients
Methods:13 Inclusion Criteria on Ambulation
Methods:14 Sample Size Calculation based on the characteristic of
balance
Methods:15 Internal Consistency, and reliability study of Berg Balance
Scale as an Outcome measure
Methods:16 Study supporting the use of Modified Barthel Index as an
Outcome measure of ADL
Methods:17 Reliability study of Isokinetic Dynamometry as an Outcome
measure to detect the muscle strength in stroke patients
 Findings of Literature Review

Reference No. Literature Review - Findings

Discuss: 18-20 Studies supporting the adverse effects of poor balance and
mobility in the activity of stroke patients
Discuss: 21-23 Studies supporting outcomes of muscle activity on the
hemiplegic side
Discuss: 24-25 Studies indicating the minimum clinical difference on
balance and mobility
Discuss: 26-30 Studies relating the muscle strength on HS with balance
and mobility
Discuss: 31-35 Studies on neural adaptations in terms of unilateral training
effecting the contralateral limbs
Discuss: 36-39 Studies on Resistance training that effects on improved
cardiopulmonary activity and thereby mobility recovery.
 Methodology
 Study Design: Experimental Design, Randomized
Controlled Trial; Single-blinded (only the assessors)

 Study Setting: A tertiary hospital rehabilitation

center (The Rehabilitation Medicine Center, People’s
Hospital of Deyang City, Deyang, China)

 Sample Design: 139 stroke patients were selected,

and they were randomly separated into a trial (n=69)
or control group (n=70)

 Ethical Approval: Received from the hospital

(No: 202104044K01); Signed informed consent was
obtained from all the participants

 Study Duration: July-December 2021 sampling was

done and each sample underwent 6 weeks of training
 Methodology (contd.)
 Sample Size: Determined using the Berg Balance
Scale (BBS) as a parameter from the reference no.14,
with a suggested value of 4.66 as the minimal
detectable change between 2 groups.

 Standard deviation value as 9

 Significance level (2-tailed) as 5%
 Power to detect a difference of 4.66 as 80%
 Arrived at a sample size of 116
 To include the possible dropout rate of 20%
 Total of 139 participants selected
 Methodology: Selection Criteria

Inclusion Criteria Exclusion Criteria

non-functional ambulators (Hoffer’s has severe cardiopulmonary diseases or

classification: II) liver or kidney dysfunction

45-75 years of age; has severe bone or joint diseases

within 6 weeks after onset co-morbid or other neurologic disorders

has sufficient cognitive and language refusal to participate

abilities
Methodology: Study Protocol-Flow Diagram
 Methodology: Outcome Measures
Outcome Variable Description
Measures
Primary: Balance 14-item BBS, each item is a 5-point ordinal scale
Berg Balance Function ranging from 0 to 4, with 0 representing
Scale (BBS) complete inability to finish a task, and 4
representing the ability to finish a task. The total
score can be between 0 and 56. An elevated
score denotes enhanced postural control
Secondary: Mobility The participants was instructed to walk as far as
Six Minute possible for 6 minutes at their own speed, along
Walk Test a length of 30-m walking track marked by a cone
(6-MWT) at each end, which instructed to the participants
to walk back
Secondary: Activity of It includes feeding, grooming, dressing, bathing,
Modified Daily toileting, bladder and bowel continence,
Barthel Index Living transfers, ambulation, and stair climbing. A score
(MBI) (ADL) of 0-20 points suggests total dependence in ADL;
21-60 points suggests severe dependence; 61-90
points suggests moderate dependence; 91-99
points suggests slight dependence. 100 points
suggests complete independence
 Methodology: Outcome Measures
Outcome Variable Description
Measures
Secondary: Maximum Each action was carried out with 5 maximal
Isokinetic Muscle contractions at 60°/s angular velocity.
Dynamometry Strength (1) Iliopsoas evaluation: The participants were in
(BBS) (Peak supine position. Transverse line passing through
(IsoMed2000, Torque) greater trochanter of femur was accepted as the
German) motion axis for hip joint. Dynamometer effort arm was
parallel to the femur, and resistance action point was
fixed at the distal femur.

(2) Quadriceps evaluation: The participants

remained seated, with the seat back adjusted to 70
degrees from the horizontal plane. Transverse line
through the femoral condyles was regarded as the
motion axis of the knee joint

(3) Biceps brachii evaluation: The participants

remained seated, with the seat back tilted to 70
degrees from the horizontal plane. A transverse line
passing through the ulnar olecranon was regarded as
the motion axis for the elbow joint. Resistance action
point was fixed at the distal forearm femur or palm
 Methodology: Intervention
Group Description

Control Group (1) Non-hemiplegic lower limb stepping forward training

Rehabilitation repeatedly, 10-15 times as a group, 3 groups.
training, including (2) Hemiplegic lower limb stepped over an obstacle or climbed a
step training and platform repeatedly, 10-15 times as a group, 3 groups.
trunk control (3) The patients stretched arms to touch distant objects repeatedly
training in in standing position. The training time was 45 min, once a day, 5
standing position days a week for 6 weeks.
(4) The participants were allowed to rest for 3-5 min during each
training.

Trial Group (1) Non-hemiplegic lower limb stepping forward training

Strength Training repeatedly with Thera-Band, 10-15 times as a group, 3 groups.
of Non-hemiplegic (2) Non-hemiplegic upper limb pulling elastic belt repeatedly in
Side standing position, 10-15 times as a group, 3 groups.
(3) Hemiplegic lower limb stepped over an obstacle or climbed a
platform repeatedly, 10-15 times as a group, 3 groups.
(4) The patients stretched arms to touch distant objects repeatedly
in standing position. The training time was also 45 min, once a day,
5 days a week for 6 weeks. The participants were allowed to rest
for 3-5 min during each training.
 Methodology: Intervention

Group Description
Both Group Also received ADL training for 30 min (dressing, transfers), bicycle
ADL Training dynamometer training for 15 min, hand function training for 30
min, and electrotherapy for 30 minutes.
The treatments were performed daily over 5 days a week for a
total of 6 weeks
Both Group All outcome assessments were completed by a physician or
Assessments physiotherapist at baseline (T0) and post-intervention (T1). The
evaluators were blinded to the study aim and participants
allocation.
Methodology: Intervention
 Methodology: Statistical Analysis
 SPSS 22.0 was employed for all data analyses.
 Descriptive statistics are presented as Mean & SD for continuous
parameters and frequency for categorical parameters.
 Baseline inter-group differences were examined via ‘t’ test for
continuous data, and Chi-square tests for dichotomous variables.
 The Mann-Whitney test was used for inter-group comparison of
non-normally distributed variables.
 The ANCOVA analyses were conducted to compare the primary
and secondary outcomes after intervention, adjusting for baseline
scores, and the magnitude of inter-group differences were
calculated
 The muscle strength gains of hemiplegic limbs from baseline to
post-intervention (T1-T0), the effect size were calculated via
Cohen’s d to assess the clinical importance of the measured
changes. Significance levels were set at P<0.05.
 Results and Interpretation

 Overall, 163 patients with stroke were screened for eligibility.

 Among them, 24 were excluded (18 patients with severe
cardiopulmonary diseases and 6 declined participation).
 Ultimately, 139 patients were selected, and they were
randomly separated into a trial (n=69) or control group
(n=70).
 During the study period, 6 patients dropped out from the
trial group and control group, respectively.
 Finally, 63 patients in trial group and 64 patients in control
group were analyzed.
 There were no associated undesirable effects either during
or after treatment.
Results and Interpretation (contd.)
Results and Interpretation (contd.)
Results and Interpretation (contd.)
 Results and Interpretation (contd.)

Primary Outcome: Both groups exhibited significant improvement in

BBS scores after intervention, there was a significant mean difference
of 6.83 points between the 2 groups after intervention.

Secondary Outcome: The trial group performed better than the

control group in mobility (6-MWT) after intervention. No significant
difference was observed in ADL between the trial and control group
after intervention. In terms of NHS muscle strength, both groups
revealed significant enhancements in the biceps brachii, iliopsoas, and
quadriceps after intervention. However, the trial group performed
significantly better than the control group after intervention.
 Discussion

 Cross-education is a process whereby unilateral strength

training is employed to enhance muscular strength of the
contralateral side.
 In current rehabilitation practice for patients with stroke,
balance and mobility remain essential goals.
 Recent studies revealed that NHS ankle dorsiflexion exercise
significantly improves the ankle dorsiflexion muscle activity
on the HS, along with balance and gait abilities in chronic
patients with stroke.
 In this study, the trial group exhibited better balance
function (BBS scores) than control group after intervention.
In terms of mobility (6-MWT), the trial group performed
better than control group after intervention, this suggested
that this training was also clinically significant at promoting
mobility in patients with stroke.
 Discussion (contd.)

 In this study, the trial group performed significantly better

than control group in strength of hip flexor, knee extensor,
and elbow flexor on the HS after intervention. This proved
that the NHS strength training can effectively enhance HS
muscle strength in patients with stroke.
 The researchers speculated that this was 1 of the reasons for
the enhanced recovery of balance function and mobility in
trial group.
 In addition, cardiopulmonary decline is a common
complication in patients with stroke and is intricately linked
to walking endurance.
 It is reported that resistance training has a positive effect on
cardiopulmonary activity in patients with stroke.
 In this study, the trial group underwent strength training of
the NHS, which was beneficial to the cardiopulmonary
fitness, and it may contribute to mobility recovery.
 Study Limitations

 Firstly, the spasticity of hemiplegic limbs were not assessed,

although no record of drug usage or botulinum toxin
administration was found to reduce spasticity in the trial
group. However, spasticity still requires further evaluation.
 Secondly, the authors only observed differences between
two groups after intervention. Hence, further studies are
required to elucidate its long-term rehabilitation efficacy.
 Conclusion

 The present study demonstrated that NHS strength training

can promote the recovery of balance, mobility, and HS
muscle strength in patients with stroke.
 Therefore, the researchers recommend NHS strength
training as a potential rehabilitation treatment item for
patients with stroke, even though it is opposite to the forced
usage paradigm that is characteristic of most stroke
rehabilitation procedures.
 Critical Appraisal

Strength Weakness
 The study focuses on the  Study included the stroke
training of NHS in contrary to patients within 6 weeks of onset
the HS. but the selection criteria are not
 Researcher clearly described
enough to indicate the condition
the results of both primary
and secondary objectives in of the samples.
the discussion.  Sampling design is not indicated
 Random allocation with in terms of probability or non-
blinded assessor to prevent probability methods.
the study bias.
 The randomization process is
not described in terms of
grouping.
 NIHSS values are included in
the baseline statistical analysis
but not stated in the selection
criteria.
 Critical Appraisal Tool

Score: 8/11 indicating the article is Good

 Supporting Study
Application of cross-migration theory in limb rehabilitation of
stroke patients with hemiplegia.
Authors: Lu YH, Fu Y, Shu J, Yan LY, Shen H.
Journal Detail: World J Clin Cases 2023; 11(19): 4531-4543

Aim: To investigate whether unilateral strength training in hemiplegic stroke

patients could lead to cross-migration, an increase in bilateral muscle strength,
and an improvement in lower limb motor function.
Methods: 120 patients with hemiplegic stroke randomized into two groups with
60 patients in each group. Both groups received routine rehabilitation treatment,
while the experimental group additionally received ankle dorsiflexion resistance
training on the healthy side for 6 weeks. Maximum voluntary contract (MVC),
changes in surface electromyography (EMG), and the lower limb motor function
were measured before and within 1 week after training.
Results: The FMA score in the experimental group improved significantly
compared to both their pre-training score and the control group's post-training
score (P < 0.05). The integrated EMG of the anterior tibialis muscle and
pulmonary intestine muscle in the experimental group were significantly different
after training than before (P < 0.05).
Conclusion: Our findings suggest that ankle dorsiflexion resistance training on
the healthy side in hemiplegic stroke patients can increase strength in the
opposite tibialis anterior muscle and antagonist's muscle, indicating a cross-
migration phenomenon of strength training.
Any Questions or Comments???

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