Strength Training – Lower Extremity

Evidence Reviewed as of before: 22-11-2011
Author(s)*: Adam Kagan, B.Sc; Anita Petzold, BSc OT
Patient/Family Information Table of contents

Introduction

Strength is determined by three factors: the muscle’s efferent pathway, the quantity of muscle and the quality of muscle. Both the muscle and the efferent pathway can be affected by stroke, either by disuse or direct assault on the central nervous system. As a result, stroke often results in loss of functional strength.

Muscle strengthening as an intervention is designed to improve the force-generation capacity of a muscle. Its application for stroke focuses on strengthening of the hemiplegic limb and enhancing functional abilities. Various types of muscle strengthening programs have been designed for the stroke clientele. Those included in this module include resistance training, force feedback, functional tasks and weight bearing tasks.

Patient/Family Information

What is strength training?

Strength training is a type of exercise used to increase muscle strength. The idea is to fatigue the muscle by doing repetitive movements. As a result, the muscles used become stronger so that next time you exercise it will be easier to do the same exercise. In other words, your body adapts to the new demands you put on it. In order to keep getting stronger, the difficulty of the exercise is increased when you get stronger. Usually the exercise is made harder when you are able to perform a certain number of repetitions. A repetition is the completion of the movement from start to finish.

Are there different kinds of strength training?

Many different types of strength training exist. For example, some require the use of large machines while some require no equipment at all. Different kinds of strength training equipment includes free weights, elastic tubing, exercise balls, workout benches and more complicated machines. Complicated machines are not necessary for most types of strength training.

The strength training programs can also vary in frequency (how many times per week) and intensity (how difficult the exercise is and how many repetitions are done). This is to be determined by the therapist.

Why strength train after a stroke?

Muscular strength is important for performing many tasks. Strength in the lower body is especially important as it is required for mobility (walking, stairs). Stroke can reduce strength by affecting both the muscle directly and also the ability to fully control the muscle. However, strength training can help reverse both of these.

Does it help people after a stroke?

Experts have studied the use of strength training for the lower body muscle groups. Walking speed and walking endurance were not improved following the strength training program. However, results suggest that functional ambulation (walking), health status/ quality of life, activities of daily living and level of physical activity are improved by lower body strength training.

What can I expect?

Most post-stroke rehabilitation programs include strengthening exercises, especially if there is a loss of strength. However, most do not follow intense lower-body strength training. In most cases the exercises will mimic everyday movements. This is because strengthening exercises have more benefit to everyday life when they are specific to what we want to improve. Examples of exercises include: sit-to-stand from different chair heights, leg extensions and leg flexions using a machine, stepping forward, backward, and sideways onto blocks of various heights to strengthen the affected leg muscles. These can be done individually or in a circuit (one after another in a specific order).

Exercise programs vary in duration but usually do not exceed one hour in total length. The time of the program is usually increased slowly.

Side effects/risks?

Exercise programs do have side effects and risks. However, careful planning can help limit these. The most common side-effect of exercise programs is muscle soreness. This is particularly common early on. Usually the soreness is worst the day following the exercises. However, as you get used to the exercises this will become reduced. So it is important to take it easy early on.

You may also experience fatigue the first few weeks of the exercise program. However, you will see a gain in energy after a few weeks.

Who provides the treatment?

Strength training programs are usually designed by physical therapists. The physical therapist or physical therapist assistant will accompany you during the start of the program. Once you are comfortable with the exercises, it is may become unnecessary to have someone assist you.

How many treatments?

Strength training programs vary depending on your goals, your needs and your tolerance. While most of the studies reviewed in this module had 6-week long exercise programs, it is to your advantage to keep exercising after the program is over. Exercise programs offer many benefits such as cardiovascular fitness (healthy heart and lungs), increased strength, stronger bones, better mood and opportunities to socialize. Exercise should be done at least 3 times per week.

How much does it cost? Does insurance pay for it?

Exercise programs are usually part of regular stroke rehabilitation. However, after discharge it may become necessary to find an area to exercise. The physical therapist or social worker may be able to help you find an area that suits your needs. While this module focuses on strength training of the legs, exercise programs are not limited to strength training. Swimming, gardening and walking are examples of other exercises that will help you stay healthy. Exercise programs can also be designed to be done in your home. It is important to find something you love to do and that is suitable.

Is lower extremity strength training for me?

A stroke can reduce your lower body strength, resulting in poor balance, affected walking (gait), difficulty with stairs and difficulty changing positions (sitting to standing). If your lower body strength has been affected, strength training may help regain strength following stroke. This could help you regain some of the abilities that have been affected.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Results Table

View results table

Outcomes

Strength training for ambulation

Biomechanical gait parameters
Effective
1b

One high quality RCT (Yang et al., 2006) and one single case study (Sullivan et al., 2006) investigated the effect of lower extremity strength training on biomechanical gait parameters in patients with stroke.

The high quality RCT found that a progressive task-oriented resistance program for the lower extremity improved gait cadence and stride length compared to no treatment.

The single case study (Sullivan et al., 2006) found that body-weight supported treadmill walking combined with limb loaded cycling improved hip and knee extension motions throughout stance and swing while walking, however ankle motion showed no noticeable change. As well, a strong correlation was found between gait improvement and magnitude of paretic leg gluteus maximus and gluteus medius activation during gait (measured by EMG).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that lower extremity strength training is more effective than no treatment in improving gait cadence and stride length in patients with stroke. One single case study also found an improvement for hip and knee extension while walking, but no change in ankle motion.

Functional ambulation
Not Effective
2a

One fair quality RCT (Glasser et al., 1986) investigated the relationship between strength training and functional ambulation (as measured by the Functional Ambulation Profile) in patients with stroke. No significant differences were found between a group of patients who received therapeutic exercise combined with isokinetic exercise therapy and a group who received therapeutic exercise alone. However, this study may not have been sufficiently powered to find significant between group differences.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that strength training is not more effective than therapeutic exercise alone in improving functional ambulation in patients with stroke.
Note: The fair quality study may not have been sufficiently powered to find significant between-group differences.

Temperospatial gait parameters
Not Effective
1b

One high quality RCT (Cooke et al., 2010) examined the efficacy of lower extremity strength training for improving temperospatial gait parameters (as measured by symmetry of step length and step time) in patients with subacute stroke and found no significant difference at 6 weeks (outcome) or 18 weeks (follow-up) between patients who received physiotherapy and functional strength training using progressive resistive exercise vs. conventional physiotherapy alone.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that lower extremity functional strength training is not more effective than conventional physiotherapy alone in improving temperospatial gait parameters in patients with subacute stroke.

Walking economy
Effective*
1B

One high quality RCT (Mead et al., 2007) studied the effect of lower extremity strength training on walking economy in patients with stroke. Immediately post intervention, there was a significant improvement in walking economy, as measured by oxygen uptake, in favour of the group of patients who received a progressive endurance and resistance training program for the lower extremity, compared to a group of patients who received relaxation training only (control). However, at a 4-month follow-up the difference was no longer significant.

Conclusion: There is moderate (level 1b) evidence from one high quality RCT that lower extremity strength training is more effective than control therapies (e.g. relaxation training) in improving walking economy immediately post intervention, but not at a 4-month follow-up, in patients with stroke.

Walking endurance
Conflicting
4

Five high quality RCTs (Moreland et al., 2003, Ouellette et al., 2004, Yang et al., 2006, Sullivan et al., 2007, Lee et al., 2008), two fair quality RCTs (Dean et al., 2000, Bourbonnais et al., 2002) and one single case study (Sullivan et al., 2006) have investigated the effectiveness of lower extremity strength training for improving walking endurance in patients with stroke.

The first high quality RCT (Moreland et al., 2003) reported no significant change in walking endurance, as assessed by the 2-minute walk test, following a program of progressive resistance exercises compared to the control group who performed the same exercises without resistance.

The second high quality RCT (Ouellette et al., 2004) found no significant change in walking endurance, as measured by the 6-minute walk test, between a group of patients who received lower-extremity progressive resistance training and a group who received upper extremity stretching (control).

The third high quality RCT (Yang et al., 2006) found that a task-oriented endurance-resistance program did improve endurance as measured by the 6-minute walk test compared to no treatment.

The fourth high quality RCT (Sullivan et al., 2007) found no significant difference between non-gait-specific strength training of the lower extremity (limb loaded cycling) compared to gait-specific ambulation exercise that had no strength training component (body-weight supported treadmill walking), as measured by the 6-minute walk test.

The fifth high quality RCT by Lee et al. (2008) found no improvement on the 6-minute walk test, following progressive resistance training for the lower extremity compared to a sham strength-training program (control).

The first fair quality RCT (Dean et al., 2000), reported significant improvements in walking endurance, as assessed by the 6-minute walk test, following a program focused on strengthening the affected lower limb combined with practicing functional tasks involving the lower limbs, compared to practicing upper limb tasks only (control).

The second fair quality RCT (Bourbonnais et al., 2002), reported significant improvements in walking endurance, as assessed by the 2-minute walk test, in favour of a group of patients who received a force feedback program for the lower paretic limb compared to a group who received a force feedback program for upper paretic limb (control).

A single case study (Sullivan et al., 2006) found that body-weight supported treadmill walking combined with limb loaded cycling improved walking endurance, as measured by the 6-minute walk test, for one patient with chronic stroke.

Conclusion: There is conflicting evidence (Level 4) regarding the effectiveness of lower extremity strength training in improving walking endurance in patients with stroke. While four high quality RCTs found that lower extremity strength training is not more effective than control therapies (e.g. resistance-free exercises, upper extremity stretching program, exercises without strength training component or sham strength-training program) in improving walking endurance in patients with stroke, one high quality RCT and two fair quality RCTs found that lower extremity strength training is more effective than control therapies (e.g. no treatment, the practice of upper limb tasks only and a force feedback program for upper paretic limb) in improving walking endurance in patients with stroke.
Note: The one high quality RCT that did find improvements in walking endurance used task-oriented strength training with some components that involved gait-related strength training movements (i.e. stepping exercises). Furthermore, one single case study found improvements in walking endurance for non-gait-specific strength training (limb loaded cycling) combined with gait-specific training that had no strength component (body-weight supported treadmill walking).

Walking speed
Conflicting
4

Seven high quality RCTs (Cooke et al., 2010, Kim et al., 2001, Lee et al., 2008, Mead et al., 2007, Ouellette et al., 2004, Sullivan et al., 2007, Yang et al., 2006), three fair quality RCTs (Bourbonnais et al., 2002, Dean et al., 2000, Teixeria-Salmela et al., 1999), two pre-post studies (Sharp & Brouwer, 1997, Cramp et al., 2006) and one single case study (Sullivan et al., 2006) have investigated the efficacy of lower extremity strength training for improving walking speed in patients with stroke.

The first high quality RCT (Cooke et al., 2010) reported no significant difference in walking speed (as measured by the 10 minute walking test or VICON movement analysis system) or community mobility (as measured by walking speed of 0.8m/sec) at 6 weeks (outcome) or 18 weeks (follow-up) between patients with subacute stroke who received physiotherapy and functional strength training using progressive resistive exercise vs. conventional physiotherapy alone.

The second high quality RCT (Kim et al., 2001) found no difference in habitual walking speed between a group of patients who received maximal isokinetic strength training compared to a group who received a program of passive range of motion exercises (control).

The third high quality RCT (Lee et al., 2008) found no difference in maximal or habitual walking speed following progressive resistance training for the lower extremity compared to a sham strength-training program.

The fourth high quality RCT (Mead et al., 2007) found no difference in habitual walking speed between a group of patients who received a progressive endurance and resistance training program for the lower extremity compared to the control group who received a relaxation program only.

The fifth high quality RCT (Ouellette et al., 2004) found no difference in self-selected and maximal walking speed (as measured by maximal gait velocities) between a group of patients who received lower-extremity progressive resistance training and a group who received upper extremity stretching (control).

Interestingly, the sixth high quality RCT (Sullivan et al., 2007) found that non-gait-specific strength training of the lower extremity (resistance cycling) was less effective for improving self-selected walking speed than ambulation exercise that had little or no strength training component (body-weight supported treadmill walking), and that when strength training of the lower-extremity was added to the gait-oriented training, there was no additional benefit.

The seventh high quality RCT (Yang et al., 2006) found that a task-oriented endurance-resistance program for the lower extremity did improve habitual walking speed compared to no treatment (control).

The first fair quality RCT (Bourbonnais et al., 2002) reported a significant improvement in habitual walking speed in favour of a group of patients who received a force feedback program of the lower paretic limb compared to a group who received a force feedback program of the upper paretic limb (control).

The second fair quality RCT (Dean et al., 2000) found significant improvements in self-selected walking speed following a program focused on strengthening the affected lower limb combined with practicing functional tasks involving the lower limbs, compared to practicing upper limb tasks only (control).

The third fair quality RCT (Teixeria-Salmela et al., 1999) found an improvement in habitual walking speed following an aerobic-strength training program compared to no training.

The first pre-post study (Sharp & Brouwer, 1997) found a significant within-group improvement in habitual walking speed for a group of patients who received an isokinetic exercise program consisting of knee extension and flexion.

The second pre-post study (Cramp et al., 2006) found a significant within-group improvement in habitual walking speed for patients who received a low intensity progressive strength program.

A single case study (Sullivan et al., 2006) found that body-weight supported treadmill walking combined with limb loaded cycling improved habitual walking speed for one patient with chronic stroke.

Conclusion: There is conflicting evidence (level 4) regarding the effectiveness of lower limb strength training in improving walking speed in patients with stroke. Six high quality RCTs report that lower limb strength training (conducted during functional strength training, maximal isokinetic strength training, progressive endurance and/or resistance training programs, resistance cycling, gait-oriented training or body-weight supported treadmill training) is not more effective than control therapies (e.g. conventional physiotherapy, passive range of motion exercises, sham strength-training programs, relaxation programs or upper extremity stretching) in improving self-selected, maximal or habitual walking speed in patients with stroke. However, one high quality RCT and three fair quality RCTs found that lower limb strength training (conducted during aerobic strength training programs or force-feedback programs) was more effective than control therapy (e.g. upper limb programs) or no therapy in improving habitual or self-selected walking speed. Furthermore, two pre-post studies and one case study also reported improved habitual walking speed following lower extremity strength training programs.
Note: Programs that were successful in improving ambulation skills often included elements such as gait-related training tasks.

Functional mobility other than ambulation

Self-reported functional mobility
Not Effective
1A

Three high quality RCTs (Mead et al., 2007, Lee et al., 2008, Cooke et al., 2010) investigated the effects of strength training on self-reported functional mobility in patients with stroke.

The first high quality RCT (Mead et al., 2007) found no significant between-group differences in self-reported functional mobility, as measured by the Rivermead Mobility Index, between a group of patients who received a progressive task-oriented resistance program for the lower extremity compared to the control group who received a relaxation program.

The second high quality RCT (Lee et al. (2008), found no improvement in perceived self-efficacy in functional mobility (measured by the Ewart Self-Efficacy Scales for stair climbing and walking) following a progressive strength-training program, compared to a sham strength-training program.

The third high quality RCT (Cooke et al., 2010) found no significant differences in functional mobility (as measured by the Rivermead Mobility Index) at 6 weeks (outcome) or 18 weeks (follow-up) between patients with subacute stroke who received physiotherapy and functional strength training using progressive resistive exercise vs. conventional physiotherapy alone.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs that lower extremity strength training is not more effective than other control treatments (e.g. relaxation program, sham strength-training or conventional physiotherapy) for improving self-reported measures of functional mobility in patients with stroke.

Sitting to ambulating
Effective
1a

Two high quality RCTs (Yang et al., 2006, Mead et al., 2007), one fair quality RCT (Bourbonnais et al., 2002) and one pre-post study (Sharp & Brouwer, 1997) investigated the effect of lower extremity strength training on ability to transition from sitting to ambulating in patients with stroke.

The first high quality RCT (Yang et al., 2006) found a significant between-group difference in transition from sitting to ambulating (as measured by the Timed Up and Go test) immediately post treatment in favour of a group of patients who received an endurance-resistance program compared to a group that received no treatment (control).

The second high quality RCT (Mead et al., 2007) also found a significant between-group difference in transition from sitting to ambulating (as measure by the Timed Up and Go test) immediately post treatment for participants who received a progressive task-oriented resistance program for the lower extremity compared to the control group who received a relaxation program (control), however the difference was no longer significant at a 4-month follow up.

The fair quality RCT (Bourbonnais et al., 2002) found no significant difference for the Timed Up and Go test between a group of patients who received a force feedback program of the lower paretic limb compared to a group who received a force feedback program for the upper paretic limb (control).

The pre-post study (Sharp & Brouwer, 1997) found no improvement in transition from sitting to ambulating (as measured by the Timed Up and Go) following an isokinetic exercise program consisting of knee extension and flexion.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that lower extremity strength training is more effective than control therapies (e.g. no treatment, relaxation) in improving the time it takes to transition from sitting to ambulating in patients post stroke. However, one fairquality RCT and one pre-post study found no improvement following a strength training program.

Sitting to standing - force
Effective
2A

One fair quality RCT (Dean et al., 2000 ) investigated the effect of lower extremity strength training on force production during sit-to-stand in patients with stroke. This fair quality RCT found a significant increase in force production through the affected leg during sit-to-stand, following a program focused on strengthening the affected lower limb combined with practicing functional tasks involving the lower limbs compared to a program of upper limb tasks only (control).

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that lower extremity strength training is more effective than upper limb exercises in improving force production during sit-to-stand in patients with stroke.

Sitting to standing - time
Not Effective
1A

Two high quality RCTs (Ouellette et al., 2004, Mead et al., 2007) investigated the effect of lower extremity strength training on the time it takes to transition from sitting to standing in patients with stroke.

The first high quality RCT (Ouellette et al., 2004) found no significant difference in ‘repeated chair rise time’ between a group of patients who received lower extremity progressive resistance training compared to a group who received upper extremity stretching (control).

The second high quality RCT (Mead et al., 2007) found no significant differences immediately post-intervention (3 months) or at follow-up (4 months) for ‘timed sit to stand’ between a group of participants who received a progressive endurance and resistance training program (that involved a sit-to-stand strength exercise) for the lower extremity, and the control group who received a relaxation program.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that lower extremity strength training is not more effective than control therapies (e.g. upper extremity stretching or relaxation program) in improving the time it takes to transition from sitting to standing in patients with stroke.

Stair climbing
Conflicting
4

Three high quality RCTs (Kim et al., 2001, Ouellette et al., 2004, Lee et al., 2008), one fair quality RCT (Teixeria-Salmela et al., 1999) and one pre-post study (Sharp & Brouwer, 1997) studied the effect of lower extremity strength training on stair climbing in patients with stroke.

The first high quality RCT (Kim et al., 2001) found that maximal isokinetic strength training did not improve stair climbing speed compared to a program of passive range of motion exercises (control).

The second high quality RCT (Ouellette et al., 2004) found no significant difference for stair climbing speed between a group of patients who received lower-extremity progressive resistance training and a group who received upper extremity stretching (control).

The third high quality RCT (Lee et al., 2008) found a significant improvement in stair climbing power following progressive resistance training for the lower extremity compared to a sham strength-training program.

The one fair quality RCT by Teixeria-Salmela et al. (1999) found an improvement in stair climbing following a strength training program compared to no training.

The pre-post study (Sharp & Brouwer, 1997) found no improvement in stair climbing following an isokinetic exercise program consisting of knee extension and flexion.

Conclusion: There is conflicting evidence (Level 4) regarding the effectiveness of lower extremity strength training in improving parameters of stair climbing in patients with stroke. While two high quality RCTs and one pre-post study found that lower extremity strength training is not more effective than control therapies (e.g. passive range of motion exercises or upper extremity stretching program) in improving stair climbing in patients with stroke, one high quality RCT reported an improvement in stair climbing power and one fair quality RCTs reported an improvement in rate of stair climbing following strength training.

Other measures

Activities of daily living (ADL)
Not Effective
1b

One high quality RCT (Mead et al., 2007) and one fair quality RCT (Inaba et al., 1973) examined the ability to resume activities of daily living (ADL) following strength training in patients with stroke.

The high quality RCT (Mead et al., 2007) found that lower-extremity strength training does not improve the ability to perform ADLs, as measured by the Nottingham Extended ADL Scale, for a group of patients who received an endurance-resistance training program compared to a group of patients who received relaxation training (control).

The fair quality RCT (Inaba et al. 1973) found that patients who received progressive resistance training combined with selective stretching significantly improved their ability to perform ADL tasks, as measured by 8 items representing functional ability, compared to a group of patients who received functional training and selective stretching only (control) and a group of patients who received active exercises combined with functional training and selective stretching.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that strength training is not more effective than control therapies (e.g. relaxation training) in improving performance of ADLs in patients with stroke. However, one fair quality RCT found that a progressive resistance program may be effective in improving ADL performance in patients with stroke.

Aerobic capacity
Not Effective
1b

One high quality RCT (Lee et al., 2008) found that strength training had no effect on peak VO2 or peak heart rate in patients with stroke following progressive strength training, compared to sham strength training.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that lower extremity strength training is not more effective than sham treatment in improving aerobic capacity in patients with stroke.

Anxiety and depression
Not Effective
1B

One high quality RCT (Mead et al., 2007) studied the effects of lower extremity strength training on anxiety and depression in patients with stroke. The study found no significant differences for anxiety and depression as measured by the Hospital Anxiety And Depression Scale between a group of patients who received an endurance-resistance training program and a group of patients who received relaxation training (control).

Conclusion: There is moderate (level 1b) evidence from one high quality RCT that lower extremity strength training is not more effective than control treatments (e.g. relaxation training) in improving depression and anxiety in patients with stroke.

Balance
Not Effective
1a

Two high quality RCTs (Yang et al., 2006, Mead et al., 2007), one fair quality RCT (Dean et al., 2000), one fair quality randomized crossover study (Page et al., 2008), one pre-post study (Weiss et al., 2000) and one single case study (Sullivan et al., 2006) studied the effect of lower extremity strength training on balance in patients with stroke.

The first high quality RCT (Yang et al., 2006) found no significant difference in balance (as measured by a step test) between a group of patients who received a progressive task-oriented resistance program for the lower extremity and a group that received no treatment (control).

The second high quality RCT (Mead et al., 2007) found no significant difference in balance (as measured by the Functional Reach Test) between a group of patients who received an endurance-resistance training program and a group of patients who received relaxation training (control).

The one fair quality RCT (Dean et al., 2000) found an improvement on the step test following a program focused on strengthening the affected lower limb combined with practicing functional tasks involving the lower limbs (including stepping exercises), compared to practicing upper limb tasks only.

The one fair quality randomized crossover study (Page et al., 2008) found a marked pre-post improvement in balance (as measured by the Berg Balance Scale), following resistance-based locomotive training. In contrast, following a home exercise program that had no strength-training component, there was no improvement on the Berg Balance Scale. No statistical analysis was done between groups for this measure.

The pre-post study (Weiss et al., 2000) found that lower extremity strength gains from a resistance program were correlated with increases in balance as measured by the Berg Balance Scale.

The single subject study (Sullivan et al., 2006) found lower extremity strength training had no effect on balance as measured by the Berg Balance Scale.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs and one single subject study that strength training is not more effective than control therapies (e.g. no treatment or relaxation training) in improving balance in patients with stroke. However, one fair quality RCT and one fair quality crossover study (without between-group analysis) reported an improvement in balance following a strength-training program, and one pre-post study suggests that lower limb strength improvement is associated with balance improvement.

Functional independence
Not Effective
1b

One high quality RCT (Mead et al., 2007) investigated the effects of strength training on functional independence (as measured by the Functional Independence Measure) in patients with stroke. The study found no significant difference between a group of patients who received an endurance-resistance training program as compared to a group of patients who received relaxation training (control).

Conclusion: There is moderate (level 1b) evidence from one high quality study that lower extremity strength training is not more effective than control therapies (e.g. relaxation training) in improving functional independence in patients with stroke.

Lower extremity strength
Conflicting
4

Five high quality RCTs (Cooke et al., 2010, Ouellette et al., 2004, Yang et al., 2006, Mead et al., 2007, Lee et al., 2008,), three fair quality RCTs (Inaba et al., 1973, Teixeria-Salmela et al., 1999, Bourbonnais et al., 2002) and three pre-post studies (Sharp & Brouwer, 1997, Badics et al., 2002, Cramp et al., 2006) examined the effect of strength training on lower extremity strength in patients with stroke.

The first high quality RCT (Cooke et al., 2010) found no significant difference in knee flexion or knee extension peak torque (as measured by an isokinetic dynamometer) at 6 weeks (outcome) or 18 weeks (follow-up) between patients with subacute stroke who received physiotherapy and functional strength training using progressive resistive exercise vs. conventional physiotherapy alone.

The second high quality RCT (Ouellette et al., 2004) found a significant improvement in lower extremity strength, as measured by leg press strength and knee extension strength, in favour of a group of patients who received lower-extremity progressive resistance training program compared to a group who received upper extremity stretching (control).

The third high quality RCT (Yang et al., 2006) found a significant between-group difference in leg strength as measured by a hand-held dynamometer in favour of a group of patients who received a progressive task-oriented resistance program for the lower extremity compared to no treatment (control).

The fourth high quality RCT (Mead et al., 2007) found no significant improvement in lower extremity strength as measured by leg extensor power between a group of patients who received an endurance-resistance training program compared to a group of patients who received relaxation training (control).

The fifth high quality RCT (Lee et al., 2008) found an improvement in peak power output on a cycle ergometer, as well as lower extremity strength (1 rep max, power and endurance tests) in both legs following progressive strength training compared to sham strength training (control).

The first fair quality RCT (Inaba et al., 1973) found a significant improvement in lower extremity strength in favour of a group of patients who received progressive resistance training combined with selective stretching compared to a group who received functional training combined with selective stretching (control) and a group who received active exercises combined with selective stretching.

The second fair quality RCT (Teixeria-Salmela et al., 1999) also found a significant improvement in lower extremity strength following a lower limb-training program compared to no intervention.

The third fair quality RCT (Bourbonnais et al., 2002) found a significant improvement in lower extremity strength following a force feedback program for the lower paretic limb compared to a force feedback program for upper paretic limb.

The first pre-post study (Sharp & Brouwer, 1997) found a significant improvement in paretic muscle strength following an isokinetic exercise program consisting of knee extension and flexion.

The second pre-post study (Badics et al., 2002) found a significant within group increase in leg extensor and supporting strength of the legs following a strength-training program aimed at restoring the extensor strength of the legs and the supporting strength of the arms.

The third pre-post study (Cramp et al., 2006) found a significant within-group improvement in isometric and concentric strength of knee extensor muscles in patients who received a low intensity progressive strength program. However, no improvement in knee flexor muscle strength was found.

Conclusion: There is conflicting evidence (level 4) as to whether lower extremity strength training is more effective than various control treatments (e.g. relaxation, upper extremity programs, no treatment, sham strength training and conventional physiotherapy) in improving lower extremity strength in patients with stroke. While three high quality RCTs, three fairquality RCTs and three pre-post studies found an improvement in lower extremity strength following lower extremity strength training, two high quality RCTs did not find an improvement.
Note: The studies used different methods for evaluating strength.

Motor function
Conflicting
4

Two high quality RCTs (Moreland et al., 2003, Ouellette et al., 2004), one fair quality RCT (Bourbonnais et al., 2002), one fair quality randomized crossover study (Page et al., 2008), two pre-post studies (Nugent et al., 1994, Weiss et al., 2000) and one single case study (Sullivan et al., 2006) have investigated the effectiveness of strength-training interventions for the improvement of motor function in patients with stroke.

The first high quality RCT (Moreland et al., 2003) found no significant differences in motor function between patients who received strength training and patients who received conventional therapy (control), as assessed using the disability inventory of the Chedoke-McMaster Scale Assessment (CMSA).

The second high quality RCT (Ouellette et al., 2004) found a significant difference in motor function (as measured by self-reported changes in function and disability using the Late Life Function and Disability Instrument) in favour of patients who received a lower-extremity progressive resistance training program as compared to patients who received an upper extremity stretching program (control).

The one fair quality RCT (Bourbonnais et al., 2002) found no significant difference in motor function (as measured by the lower extremity section of the Fugl-Meyer Assessment) between a group of patients who received lower extremity strength training and a group of patients who received upper-extremity strength training.

The one fair quality randomized crossover study (Page et al., 2008) found a marked pre-post improvement in motor function (as measured by lower extremity section of the Fugl-Meyer Assessment), following resistance-based locomotive training . In contrast, following a home exercise program that had no strength training component, there was only a negligible improvement on the lower extremity section of the FMA. No statistical analysis was done between groups.

Two pre-post studies used the Motor Assessment Scale (MAS) as a primary outcome measure to explore the relationship between strength-training interventions and motor function. Nugent et al. (1994) reported a significant improvement in MAS score following a set regimen of weight bearing leg extensor exercise (WBE). Similarly, Weiss et al. (2000) noted significant improvements in MAS scores following a 12-week program of resistance training.

The single case study by Sullivan et al. (2006) found an improvement in motor ability as measured by the lower extremity section of the Fugl-Meyer Assessment immediately post intervention, however this difference was no longer notable 6 months after baseline.

Conclusion: There is conflicting evidence (level 4) as to whether strength training improves motor function in patients with stroke. While one high quality RCT, one fair quality crossover (without between-group analysis) and two pre-post studies reported improved motor function, another high quality RCT and one fair quality RCT found that strength training was not more effective than control therapies (e.g. conventional therapy, upper extremity strength training) in improving motor function in patients with stroke. Further, while the single case study found an improvement immediately post intervention, the improvement was no longer notable 6 months post intervention.
Note: Because of the variations in the intervention times and exercise programs, future studies are warranted to better understand the effect of the different strength training regiments on motor function. It should also be noted that all studies used different functional assessments.

Physical activity
Effective
2a

One fair quality RCT (Teixeria-Salmela et al., 1999) examined the use of strength training to improve physical activity (as measured by the Human Activity Profile and the Adjusted Activity Scale) in patients with stroke. Significant improvements were found for those who had received the intervention compared to those who had not received strength training.

Conclusion: There is limited (level 2a) evidence from one fair quality RCT that strength training interventions may be effective in increasing physical activity in patients with stroke.

Quality of life
Not Effective
1A

Four high quality RCTs (Cooke et al., 2010, Kim et al., 2001, Mead et al., 2007, Lee et al., 2008, ) and one single case study (Sullivan et al., 2006) investigated the effects of lower extremity strength training on quality of life in patients with stroke.

The first high quality RCT (Cooke et al., 2010) found no significant difference in health status or health-related quality of life (as measured by the EuroQuoL) at 6 weeks (outcome) or 18 weeks (follow-up) between patients with subacute stroke who received physiotherapy and functional strength training using progressive resistive exercise vs. conventional physiotherapy alone.

The second high quality RCT (Kim et al., 2001) found no improvement on the mental or physical health items of the Medical Outcomes Short Form-36 (SF-36) for patients who received a maximal isokinetic strengthening program compared to patients who received a passive range of motion intervention (control).

The third high quality RCT (Mead et al., 2007) found that lower extremity strength training significantly improved the role-physical items of the SF-36 for patients who received an endurance-resistance training program compared to a group of patients who received relaxation training (control). However, no significant between-group difference was found for the physical functioning, general health, vitality and mental health items of the SF-36.

The fourth high quality RCT (Lee et al., 2008) found no improvement in quality of life, as measured by the SF-36, following a progressive strength training of the lower extremities compared to a sham strength training program.

The single case study (Sullivan et al., 2006) found that a patient who received lower extremity strength training improved on the strength, mobility, emotion, and social participation sub-scales of the Stroke Impact Scale (SIS), however no improvement was found for the hand function, activities of daily living (ADL), communication, memory and thinking subscales of the SIS.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs that lower extremity strength training is not more effective than a variety of control treatments (e.g. conventional physiotherapy, passive ROM, or sham strength training) in improving quality of life in patients with stroke.
Note: However, one high quality RCT found a significant difference in the role-physical items of the Medical Outcomes Short Form-36 (SF-36), in favour of patients who received the lower extremity strength training program as compared to the control group who received relaxation training. As well, one single case study found an improvement in some aspects of quality of life following strength training post-stroke.

Spasticity
Not Effective
1B

One high quality RCT (Moreland et al., 2003), two fair quality RCTs (Teixeria-Salmela et al., 1999, Bourbonnais et al., 2002) and three pre-post studies (Sharp & Brouwer, 1997, Badics et al., 2002, Cramp et al., 2006) examined the effect of strength training on spasticity in patients with stroke.

The one high quality RCT (Moreland et al (2003), found no change in spasticity (as measured by the Ashworth Scale) following progressive resistance exercises compared to the control group who performed the same exercises without resistance.

The first fair quality RCT (Teixeria-Salmela et al., 1999) found no change in spasticity, as measured by the pendulum test for the knee and controlled resistance to passive stretch for the ankle, following a lower limb training program compared to no intervention. However this study may not have been sufficiently powered to find significant results.

The second fair quality RCT (Bourbonnais et al., 2002) found no change in spasticity (no measure specified) following a force feedback program for the lower paretic limb compared to a force feedback program for the upper paretic limb.

The first pre-post study (Sharp & Brouwer, 1997) found no change in spasticity, as measured by the pendulum test, following an isokinetic exercise program consisting of knee extension and flexion.

The second pre-post study (Badics et al., 2002) found no change in spasticity, as measured by the Ashworth scale, following an exercise program aimed at restoring the extensor strength of the legs and the supporting strength of the arms, possibly due to an unusually high level of spasticity at baseline.

The third pre-post study (Cramp et al., 2006) found no change in lower extremity spasticity, as measured by the Ashworth scale, in patients who received a low intensity progressive strength program.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT, two fair quality RCTs and three pre-post studies that lower extremity strength training is not more effective than control therapies in improving lower extremity spasticity in patients with stroke.

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