Stroke: leg and arm training may improve recovery.

Clinical bottom line (level 1b-)

  1. Patients who have had a middle cerebral artery stroke and were given leg training may be more likely to have an improvement in activities of daily living score, walking ability and dexterity than those given control treatment.
  2. Patients who were given arm training, may be more likely to have an improvement in dexterity.
  3. There was no difference in activities of daily living score or walking ability in those given arm training.
Kwakkel et al: Lancet 1999; 354: 191-196
Expires January 2003

The study

Single-blinded ?concealed randomised trial ?with intention-to-treat
Setting: seven hospitals, The Netherlands

101 patients (aged mean 66 years, 57% female) first-ever stroke in the middle cerebral artery and impaired motor function of the arm and leg

Excluded if
  • aged <30 or >80 years old
  • able to walk at first assessment
  • complicating medical history
  • severe deficits in communication, memory or understanding
  • no consent


    • Control Group: (n = 37, 34 analysed): immobilisation of paretic arm and leg by means of an inflatable pressure splint, applied with the patients supine for 30 minutes on 5 days per week
    Experimental Group: (n = 33, 29 analysed): arm training applied by local physical and occupational therapists for 30 minutes on 5 days per week for 20 weeks after stroke. Arm training consisted of leaning, punching a ball, grasping and moving objects.
    Experimental Group: (n = 31, 26 analysed): leg training in the same schedule as arm training. Leg training consisted of sitting, standing and weight-bearing exercises during standing and walking, with an emphasis on achieving stability and improving gait velocity.
    All patients were given 15 minutes per day leg rehabilitation, 15 minutes per day arm rehabilitation and 1.5 hours per week activities of daily living training by an occupational therapist.
    100% followed for 26 weeks

    The evidence

    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    mean activities of daily living score (Barthel Index)- control versus arm 17.0
    ()     		17.0
    ()     		0.00
    ( to )
    mean activities of daily living score- control versus leg 17.0
    ()     		19.0
    ()     		-2.00
    ( to )
    mean walking ability (functional ambulation category)- control versus arm 4.00
    ()     		4.00
    ()     		0.00
    ( to )
    walking ability- control versus leg 4.00
    ()     		5.00
    ()     		-1.00
    ( to )
    dexterity (Action Research arm test)- control versus arm 0.00
    ()     		4.00
    ()     		-4.00
    ( to )
    dexterity- control versus leg 0.00
    ()     		3.00
    ()     		-3.00
    ( to )

    Comments

    1. Standard deviations of the mean were not reported, so confidence intervals for mean differences could not be calculated. It is not therefore possible to determine whether or not any differences are significant.

    Citation

    1. Kwakkel G, Wagenaar RC, Twisk JWR, et al: Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomised trial. Lancet 1999; 354: 191-196
    Contributor: Clare Wotton and Musab Hayatli, January 2000
    Reviewer:

    Clinical Question.
    Patient stroke
    Intervention or Exposure arm and leg training
    Comparison control
    Outcome activities of daily living and walking ability