Section précédente 3. Amplitude des mouvements et spasticité après un AVC Prochaine section 5. Prévention et prise en charge des chutes
NOUVEAU Prestation de soins de réadaptation post-AVC pour optimiser le rétablissement des capacités fonctionnelles
NOUVEAU Prestation de soins de réadaptation post-AVC pour optimiser le rétablissement des capacités fonctionnelles

4. Membres inférieurs, équilibre, mobilité et exercices aérobiques

Recommandations et/ou facteurs cliniques
4.0 Considérations générales
  1. Les personnes doivent participer à un programme d’exercices pertinent, motivant, qui comprend la pratique répétitive et progressive d’une tâche particulière, et qui est axé sur des objectifs afin d’améliorer la mobilité et l’aptitude à effectuer des transferts [recommandation forte; qualité élevée des données probantes].
4.1 Capacités fonctionnelles des membres inférieurs et marche
  1. Un programme d’exercices qui comprend la pratique répétitive et progressive d’une tâche particulière, et qui est axé sur des objectifs doit être offert pour améliorer la distance et la vitesse de marche ainsi que l’exécution de certaines tâches impliquant la mobilité, comme de se lever à partir d’une position assise [recommandation forte; qualité élevée des données probantes].
    1. Les programmes d’exercices axés sur une tâche particulière, qu’ils soient suivis individuellement ou en groupe, sont efficaces et peuvent être envisagés [recommandation forte; qualité élevée des données probantes].
  2. Des exercices de résistance doivent être envisagés pour les personnes présentant une déficience légère ou modérée des membres inférieurs afin d’améliorer la force et les fonctions motrices; toutefois, leur incidence sur la mobilité fonctionnelle est limitée [recommandation forte; qualité élevée des données probantes]. 
  3. L’entraînement à la marche sur tapis roulant (avec ou sans soutien du poids corporel) pourrait être utilisé pour améliorer la distance et la vitesse de marche comme traitement complémentaire de l’entraînement au sol ou lorsque ce dernier n’est pas possible ou approprié [recommandation forte; qualité élevée des données probantes].
  4. Les dispositifs d’assistance électromécaniques (robotiques) d’entraînement à la marche ne sont pas recommandés par rapport à l’entraînement à la marche traditionnel [recommandation forte; qualité élevée des données probantes]. 
  5. La stimulation auditive rythmique (SAR) doit être utilisée pour améliorer la marche (c’est-à-dire la vitesse, la cadence et la longueur de foulée) et les capacités fonctionnelles [recommandation forte; qualité élevée des données probantes].
  6. La stimulation électrique fonctionnelle (SEF) doit être utilisée pour améliorer l’équilibre, la vitesse de marche et la mobilité chez certaines personnes ayant subi un AVC [recommandation forte; qualité élevée des données probantes].
  7. Les orthèses pédi-jambières doivent être utilisées pour aider certaines personnes chez qui un pied tombant a été diagnostiqué. Un suivi doit être effectué pour déterminer leur efficacité à améliorer la vitesse de marche et l’équilibre [recommandation forte; qualité élevée des données probantes]. 
  8. Les exercices aquatiques sont recommandés pour améliorer la vitesse de marche et la mobilité [recommandation forte; qualité élevée des données probantes].
  9. L’entraînement par la réalité virtuelle non immersive peut être envisagé pour améliorer les capacités fonctionnelles des membres inférieurs, l’équilibre et la marche (c’est-à-dire la vitesse, la cadence et la longueur de foulée) en complément d’un entraînement à la marche traditionnel [recommandation forte; qualité modérée des données probantes].
  10. La rétroaction biologique, sous la forme de signaux visuels et auditifs, peut être utilisée pour améliorer les capacités fonctionnelles des membres inférieurs [recommandation forte; qualité modérée des données probantes]. 
  11. La pratique de l’imagerie mentale peut être envisagée en complément d’un entraînement à la marche afin d’améliorer la vitesse de marche [recommandation forte; faible qualité des données probantes]. 

Considérations cliniques de la section 4.1

  1. Le besoin en matière d’appareils spécialisés, comme les dispositifs d’aide à la marche, les fauteuils roulants et autres appareils fonctionnels, doit être évalué au cas par cas.
    1. Une fois l’équipement fourni, les personnes ayant subi un AVC devraient être réévaluées, s’il y a lieu, pour déterminer quels sont les progrès qui ont été accomplis, si des changements ou des ajustements sont nécessaires, et si l’équipement n’est plus nécessaire et quand ce sera le cas. 
4.2 Équilibre
  1. Pour améliorer l’équilibre après un AVC, les traitements suivants doivent être envisagés (en plus des recommandations 4.1 vi et ix) :  
    1. L’entraînement musculaire du tronc ou l’entraînement pour le rétablissement de l’équilibre en position assise [recommandation forte; qualité élevée des données probantes].
    2. L’entraînement pour le rétablissement de l’équilibre en milieu aquatique [recommandation forte; qualité élevée des données probantes]. 
    3. Le tai-chi [recommandation forte; qualité élevée des données probantes].
    4. L’entraînement pour le rétablissement de l’équilibre combiné à la rétroaction visuelle ou à l’imagerie motrice peut être envisagé comme traitement complémentaire [recommandation forte; qualité modérée des données probantes].
    5. L’utilisation de surfaces instables et de planches d’équilibre [recommandation forte; qualité modérée des données probantes].
    6. L’entraînement par vibration globale du corps est recommandé comme traitement complémentaire [recommandation conditionnelle; qualité élevée des données probantes]. 
  2. La rétroaction biologique sur plateforme de force n’est pas recommandée par rapport à un entraînement traditionnel pour le rétablissement de l’équilibre [recommandation forte; qualité élevée des données probantes].

Considérations cliniques de la section 4.2

  1. Les thérapeutes doivent prendre en considération le contrôle de l’équilibre, tant volontaire que réactif, dans le cadre de l’évaluation et du traitement.
4.3 Capacité de se lever à partir d’une position assise
  1. L’entraînement « assis-debout » doit être envisagé pour améliorer la capacité de se lever à partir d’une position assise [recommandation forte; qualité modérée des données probantes].
4.4 Entraînement aérobique

Voir les lignes directrices AEROBICS (en anglais seulement) pour obtenir de plus amples renseignements.107

  1. Pour les personnes ayant subi un AVC dont l’état de santé est stable, il faut envisager un examen de la capacité de participer à des exercices aérobiques [recommandation forte; qualité modérée des données probantes].
  2. L’évaluation préalable à la participation doit comprendre une évaluation des comportements relatifs à l’activité physique, des antécédents en matière d’exercices et des antécédents médicaux, ainsi qu’un examen physique, le tout réalisé par des professionnels de la santé qualifiés ayant l’expertise appropriée en matière d’entraînement aérobique, afin de déterminer les facteurs qui nécessitent une attention particulière ou qui constituent une contre-indication aux exercices aérobiques [recommandation forte; qualité modérée des données probantes].
  3. Si le plan prévoit un entraînement aérobique d’intensité légère (p. ex. < 40 % de la valeur prédite de la réserve de fréquence cardiaque), une épreuve d’effort sous maximale peut être envisagée [recommandation forte; qualité modérée des données probantes].
  4. Des tests de dépistage par exercices aérobiques doivent être réalisés avec une surveillance des signes et symptômes cliniques, de la fréquence cardiaque, de la pression artérielle, ainsi qu’une évaluation de la perception de l’effort [recommandation forte; qualité modérée des données probantes]. 
    1. Au cours d’une épreuve d’effort limitée aux symptômes, un électrocardiogramme doit également être utilisé pour surveiller l’électrocardiographie [recommandation forte; qualité modérée des données probantes].
  5. Les exercices aérobiques personnalisés qui font travailler les grands groupes musculaires doivent être intégrés dans un programme complet de réadaptation post-AVC visant à améliorer l’endurance cardiovasculaire, l’équilibre et la marche [recommandation forte; qualité élevée des données probantes].
    1. Pour obtenir des résultats, les personnes doivent s’exercer pendant un minimum de 8 semaines [recommandation forte; qualité élevée des données probantes], à raison d’au moins 8 fois par semaine, en progressant à des périodes de 5 à 20 minutes ou plus (sans compter les périodes d’échauffement et de récupération) par séance, selon leur niveau de tolérance [recommandation forte; qualité modérée des données probantes]. 
    2. Les signes et symptômes cliniques, la fréquence cardiaque, la pression artérielle et l’évaluation de la perception de l’effort, ainsi que d’autres facteurs médicaux pertinents, doivent être surveillés pendant l’entraînement pour assurer la sécurité de la personne et l’atteinte de l’intensité cible de l’exercice [recommandation forte; qualité modérée des données probantes].
  6. Afin d’assurer le maintien à long terme des bienfaits de l’entraînement sur la santé, il est recommandé de planifier la transition des exercices aérobiques structurés vers un entraînement plus autonome à domicile ou dans la communauté [recommandation forte; qualité modérée des données probantes].
    1. Des stratégies doivent être employées pour surmonter des obstacles particuliers à l’activité physique en lien avec la personne ayant subi un AVC, les prestataires de soins de santé, la famille et l’environnement [recommandation forte; qualité modérée des données probantes].
Justification +-

Les troubles de la mobilité et de l’équilibre sont très fréquents après un AVC, en particulier chez les personnes ayant subi un AVC plus grave. Ils nuisent à la sécurité de la personne, à sa capacité à effectuer les activités de la quotidienne et à conserver son autonomie. Ces problèmes résultent souvent d’une combinaison de faiblesse musculaire, de coordination réduite et de déficits sensoriels, qui peuvent rendre difficiles certains mouvements, comme se lever et marcher. La perte d’équilibre accroît le risque de chute, ce qui complique encore davantage les efforts nécessaires au rétablissement et à la réadaptation. Des stratégies de réadaptation efficaces, notamment la physiothérapie et l’entraînement pour le rétablissement de l’équilibre, sont essentielles pour aider les personnes à retrouver leur mobilité, à renforcer leur stabilité et à améliorer leur qualité de vie globale après un AVC.

Les personnes ayant subi un AVC ont souligné l’importance de la répétition, de la progression et de la variation des programmes de réadaptation post-AVC en ce qui a trait à la marche, à la mobilité et à l’équilibre. Les occasions d’exercer leurs habiletés dans divers environnements qui reproduisent des situations de la vie réelle sont également jugées utiles. Les personnes ayant subi un AVC soulignent l’importance de la participation des membres de leur famille et de leurs aidantes et aidants lorsqu’ils reçoivent de l’information et de la formation sur la marche, la mobilité et les exercices aérobiques (notamment des instructions pour pratiquer des exercices aérobiques à domicile et utiliser des appareils fonctionnels de façon prudente et appropriée).

Exigences pour le système +-

Pour une évaluation et une prise en charge appropriées et en temps opportun de la mobilité de base, du contrôle postural, des capacités fonctionnelles des membres inférieurs, de la marche et de l’aptitude aux transferts, les organismes doivent optimiser les éléments suivants du système :

  1. La disponibilité de soins de l’AVC organisés pendant la période de réadaptation post-AVC, notamment des unités de réadaptation post-AVC dotées d’une équipe interdisciplinaire ayant reçu la formation appropriée et comptant le personnel nécessaire.
  2. Une évaluation initiale et continue uniformisée, effectuée par des prestataires de soins de santé ayant la formation et l’expérience appropriées en matière de réadaptation post-AVC.
  3. La mise en place de processus qui permettent d’accéder en temps opportun à des modalités de traitement et à des équipes interdisciplinaires et spécialisées en réadaptation post-AVC.
  4. L’accès en temps opportun à une réadaptation de modalité et d’intensité appropriées pour les personnes ayant subi un AVC.
  5. La mise en place de processus pour assurer une évaluation adéquate des personnes afin de répondre à leurs besoins en matière d’équipement (p. ex. évaluation des besoins en position assise).
  6. L’accès à des appareils et accessoires fonctionnels nécessaires pour favoriser la sécurité, la participation aux activités et l’autonomie. Cet équipement doit être abordable et des programmes doivent être mis en place pour les personnes qui n’ont pas les moyens de se le procurer. 
  7. L’accès des prestataires de soins de santé à des dispositifs appropriés pour effectuer une évaluation complète visant à mettre au point un programme d’exercices aérobiques d’intensité appropriée (p. ex. épreuve d’effort contrôlée par électrocardiogramme).
Indicateurs de rendement +-

Indicateurs du système

  1. Accès en tout temps à des services de réadaptation post-AVC en milieu hospitalier.
  2. Proportion de personnes qui séjournent dans une unité de réadaptation post-AVC en milieu hospitalier et en milieu communautaire dans le cadre de leurs soins après un AVC au sein d’une région où sont offerts des services de prise en charge de l’AVC.

Indicateurs de processus

  1. Intervalle médian entre l’admission dans une unité de soins de courte durée en raison d’un AVC et l’évaluation du potentiel de réadaptation effectuée par des spécialistes dans ce domaine.
  2. Durée médiane du séjour dans une unité de réadaptation post-AVC pendant la réadaptation active en milieu hospitalier.
  3. Nombre médian d’heures par jour de traitement direct axé sur une tâche particulière (minimum de trois heures) offert par l’équipe interdisciplinaire de prise en charge de l’AVC.
  4. Nombre médian de jours par semaine de traitement direct axé sur une tâche particulière (minimum de cinq jours) offert par l’équipe interdisciplinaire de prise en charge de l’AVC.

Indicateurs axés sur la personne

  1. Ampleur des changements (amélioration) dans les scores relatifs à l’état fonctionnel, selon le test des six minutes de marche, entre l’admission dans un programme de réadaptation en milieu hospitalier et le congé. 
  2. Changements (amélioration) dans les scores relatifs à l’état fonctionnel (p. ex. selon les résultats liés à la locomotion de la MIF), entre l’admission dans un programme de réadaptation en milieu hospitalier et le congé.
  3. Ampleur des changements (amélioration) dans les scores relatifs à l’état fonctionnel (p. ex. selon les résultats sur la sous-échelle pour les membres inférieurs de l’échelle d’évaluation d’AVC Chedoke-McMaster), entre l’admission dans un programme de réadaptation hospitalier et le congé. 
  4. Ampleur des changements dans les scores relatifs à l’état fonctionnel, selon une échelle d’évaluation uniformisée (p. ex. la MIF), entre l’admission dans un programme de réadaptation en milieu hospitalier et le congé (moyenne et médiane).
  5. Ampleur des changements de l’état fonctionnel des membres inférieurs selon une échelle d’évaluation uniformisée (p. ex. l’échelle d’évaluation d’AVC Chedoke-McMaster), entre l’admission dans un programme de réadaptation hospitalier et le congé.
Ressources pour la mise en œuvre et outils de transfert des connaissances +-

Les ressources et les outils ci-dessous, qui sont externes à Cœur + AVC et aux Recommandations, peuvent être utiles à la mise en œuvre des soins de l’AVC. Cependant, leur présence ne constitue pas une approbation réelle ou implicite par l’équipe des pratiques optimales de soins de l’AVC ni par Cœur + AVC. Nous vous encourageons à examiner ces ressources et ces outils d’un œil critique et à les mettre en œuvre dans votre pratique à votre discrétion.

Renseignements destinés aux prestataires de soins de santé

Ressources destinées aux personnes ayant subi un AVC, à leur famille et à leurs aidantes et aidants 

Résumé des données probantes (en anglais seulement) +-

Evidence Table and Reference List 4

Lower Extremity Gait Training

Task Oriented Training (Task-Specific Training
Task oriented training (also called task-specific training) involves active practice of task-specific motor activities. Repeated motor practice has been shown to improve walking speed and functional ambulation.

A Cochrane review by English et al. 109 pooled findings from 17 RCTs that compared circuit class training, provided for a minimum of once-weekly sessions for a minimum of 4 weeks, with no therapy, sham therapy, or another therapy modality. Only studies that reported interventions with a focus on repetitive practice of functional tasks arranged in a circuit, with the aim of improving mobility, were included.  Pooling the results from 10 trials, compared with any other intervention, circuit class training was associated with a significantly greater increase in distanced walked (m) in the 6-minute walk test (6MWT) (MD=60.86, 95% CI 44.55 to 77), a distance which exceeded the minimal clinically important difference of 34.4 metres. The mean gait speed in the intervention groups was 0.15 metres/ second faster (95% CI 0.10 to 0.19 m/s) compared with the control group. Other outcomes with scores significantly higher in the intervention group included Timed-up-and Go (TUG) test, Stroke Impact Scale, Functional Ambulation Classification and the Rivermead Mobility Index. In another Cochrane review, French et al. 14 examined task-specific training on upper and lower extremity functions compared with usual care, an alternative intervention, or no care. Lower extremity repetitive task-oriented training interventions were examined in 17 trials. Two trials focused on sit-to-stand practice, 6 trials focused on walking practice, while 4 trials investigated interventions that focused specifically on sitting balance trunk control, and balance. Repetitive task training was associated with significantly greater improvements in walking distance (MD= 34.80 metres, 95% CI 18.19 to 51.41 metres; 9 studies) and functional ambulation (SMD= 0.35, 95% CI 0.04 to 0.66; 8 studies), sit-to-stand post treatment (SMD=0.35, 95% CI 0.13 to 0.56, 7 studies) and standing balance or reach (SMD= 0.24, 95% CI 0.07 to 0.42; 9 studies).

Resistance Training
Many individuals experience muscle weakness as a consequence of stroke. Strength training may help to improve measures of gait and balance. Flansbjer et al. 110, 111 randomized 24 persons living in the community a minimum of 6 months post stroke to a training group that participated in supervised progressive resistance training of the knee muscles twice weekly for 10 weeks, or to a control group in which participants continued their usual daily activities. The authors found that on the paretic side, the mean dynamic knee muscle strength extension and flexion in the intervention group had improved significantly more at the end of treatment and was maintained at 4-year follow-up compared to the control group. However, there were no significant differences between groups in mean improvement on the TUG test, gait speed or distance traveled on the 6MWT at four years. Cooke et al. 112 randomized participants with subacute stroke (mean 1 month) to one of three treatment groups for a duration of 6 weeks: 1) conventional physiotherapy (CPT) + Functional Strength training (FST); 2) extra intensity training (CPT + CPT); or 3) CPT alone. Following the intervention both experimental groups showed improvement in walking speeds over the CPT alone group, but this reached significance in the CPT + CPT group. The CPT + CPT group also showed significant improvement in the number of participants with a walking speed over 0.8m/s compared to the CPT group. No significant differences were noted between-groups for torque about the knee, symmetry step length, symmetry step time, the Rivermead score, or on the EuroQoL. At the 12-week follow-up no significant differences were identified between groups.

Treadmill Training with and without Body Weight Support
In a Cochrane review, Mehrholz et al. 113 included the result of 56 trials (n=3,105) and concluded that patients with stroke who received treadmill training (with or without body weight support) in combination with physiotherapy had significantly improved gait velocity (MD=0.06 m/s, 95% CI 0.03 to 0.09) and greater walking endurance (MD=14.19 metres, 95% CI 2.92 to 25.46), when assessed at the end of treatment. Among studies evaluating treadmill training with body weight support, patients were no more likely to achieve independent walking than patients receiving gait training without these devices (risk difference= -0.00, 95% CI -0.02 to 0.02), nor was gait velocity or walking endurance increased significantly at the end of scheduled follow-up (MD=0.03 m/s, 95% CI -0.05 to 0.10 and MD= 21.64 m, 95% CI -4.70 to 47.98). In the MOBILISE trial, 114, 115 126 patients were randomized to an experimental or a control group within 28 days of stroke and received treatment until they achieved independent walking or for as long as they remained in hospital. Participants in both groups received 30 minutes of walking practice 5 days/week. Additional lower extremity therapy was provided for an additional 30 minutes/day. Participants in the experimental group undertook up to 30 minutes per day of treadmill walking with sufficient body weight support such that initially, the knee was within 15 degrees of extension in mid stance. The control group received up to 30 minutes of over-ground walking training, with the use of aids, if required. Although there were no differences in the proportion of independent ambulators between groups at one, two or 6 months, participants in the experimental group achieved independence in ambulation a median of 14 days sooner. In the Locomotor Experience Applied Post Stroke (LEAPS) trial, Nadeau et al. 116 randomized 408 patients with residual paresis who were able to walk 10 feet with no more than one-person assistance and within 45 days of stroke onset to one of 3 programs: 1) Locomotor training program (LTP), 2) Home exercise program (HEP), or 3) Usual Care (UC). Both LTP and HEP programs were of similar duration and intensity (90-minute sessions, 3 times/week) for 12-16 weeks, for a total of 30 to 36 exercise sessions. At 6 months, 50.4% of LTP, 49.2% of HEP, and 32.2% of UC patients had improved to a higher functional walking level with no significant differences between the LTP and HEP groups.

Electromechanical/Robot-Assisted Gait Training Devices
In an updated Cochrane review, Mehrholz et al. 117 included 62 trials including 2,440 participants with difficulty walking following a stroke and examined the effectiveness of electromechanical and robot-assisted gait training for improving walking after stroke. Treatments included electromechanical and robot-assisted gait training devices (with or without electrical stimulation) which are designed to assist stepping cycles by supporting body weight and automating the walking therapy process with the addition of physiotherapy compared with physiotherapy or routine care only. Electromechanical-assisted gait training in combination with physiotherapy increased the odds of participants becoming independent in walking at the end of treatment (Odds ratio [OR]=2.01, 95% CI 1.51 to 2.69; 38 trials; GRADE: high certainty); however, the benefit was lost at the end of follow-up, which averaged 22.3 weeks (OR=1.93, 95% CI 0.72 to 5.13; 6 trials; GRADE: low certainty). At the end of the intervention, walking speed was also significantly faster in the experimental group (MD=0.06 m/s, 95% CI 0.02 to 0.1; 42 trials: GRADE: low certainty), with the benefit lost at the end of follow-up, which averaged 19 weeks (MD=0.07 m/s, 95% CI - 0.03 to 0.17; 13 trials; GRADE: low certainty). At neither the end of the intervention, nor at follow-up (mean of 18 weeks), was walking capacity (distance walked in 6 minutes) significantly improved in the experimental group (MD=10.86 meters, 95% CI -5.72 to 27.44; 24 trials and MD=7.76 meters, 95% CI -21.47 to 36.99; 11 trials. GRADE: moderate). Molteni et al. 118 included 75 patients with first-ever stroke, with onset within the previous 35 days, and limited ambulation capacity in the Stroke Rehabilitation with Exoskeleton-assisted Gait. (EKSOGAIT) trial. In addition to conventional rehabilitation that all patients received for 120 minutes daily, 6 days a week, Patients were also randomized to an experimental group and received 15 sessions (60 minutes each, 5 days/week for 3 weeks) with the Ekso™ device (an exoskeleton) or the same amount of conventional gait training (control group). There was no significant difference in the primary outcome (6MWT) between groups at the end of the intervention. The mean distance walked from baseline to end of treatment increased from 48.60 meters to 139.24 m in the experimental group and from 44.29 meters to 149.43 in the control group.

Rhythmic Auditory Stimulation (RAS)
Rhythmic auditory cueing or stimulation, whereby walking is synchronized to a rhythmic auditory cue, may help to improve motor learning following a stroke. Ghai & Ghai 119 examined music-based auditory cueing in addition to conventional physical therapy, including the results from 38 trials (11 RCTs). RAS was associated with significantly improved  gait velocity (Hedges’ g=0.68, 95% CI 0.42 to 0.93; 25 trials included), increased stride length (Hedges’ g=0.50, 95% CI 0.26 to 0.73; 20 trials included), improved cadence (Hedges’ g=0.86, 95% CI 0.50 to 1.22; 23 trials included) and improvement in TUG  (g= -0.76, 95% CI -1.36 to −0.16; 6 trials included). Yoo & Kim 120 included the results of 8 RCTs (n=242) comparing intentional synchronization of target movement to externally generated rhythmic auditory cueing with traditional rehabilitative interventions or other controlled interventions in persons with hemiparesis following stroke. RAS was associated with large significant effect sizes for all lower extremity outcomes, including gait velocity (Hedges’ g=0.98, 95% CI 0.69 to 1.28), cadence (Hedges’s g=0.84, 95% CI 0.63 to 1.15) and stride length (Hedges’ g=0.76, 95% CI 0.47 to 1.05).

Virtual Reality (VR)
Zhang et al.121 included 87 RCTs including 3,540 participants with stroke with upper and lower disability, with varying chronicity of stroke. In this systematic review, trials compared VR rehabilitation interventions, with many trials using commercially available devices such as Xbox Kinect TM vs. conventional rehabilitation or placebo therapy. At the end of treatment, VR interventions were associated with significantly higher Fugl-Meyer Assessment-lower extremity (FMA-LE) scores (MD=3.01, 95% CI 1.91–4.11; 16 trials, n=732), Functional Ambulation Categories (FAC) scores (MD= 0.47, 95% CI = 0.14–0.79; 5 trials, n=260), and gait speed (MD=11.79 cm/sec, 95% CI 8.48–15.11; 9 trials, n=310), compared with conventional rehabilitation. A Cochrane review 33 included the results of 72 trials, which evaluated the effect of virtual reality and interactive video gaming. While most of the trials assessed upper intervention, a few assessed mobility outcomes. In these trials, virtual reality was not associated with significant improvements in gait speed, balance or TUG tests at the end of the intervention compared with conventional therapy. Iruthayarajah et al. 122 included the results of 22 RCTs specifically examining the use of virtual reality in the chronic stage of stroke to improve balance. Interventions included the Wii Fit balance board, and treadmill training and postural training combined with virtual reality applications. Combining the results of 12 trials, VR interventions were associated with a significantly greater improvement in Berg Balance Scale (BBS) scores (MD=2.94, 95%CI 1.82–4.06, p<0.001). Gibbons et al. 123 included the results of 22 trials (552 participants) evaluating the effects of VR interventions on lower extremity outcomes post stroke. Pooled analyses were possible for studies including patients in the chronic stage of stroke. In the VR group, functional balance was improved significantly more following treatment (SMD=0.42, 95% CI 0.11 to 0.73), but not at follow-up (SMD=0.38, 95% CI -0.73 to 1.50). Gait velocity, cadence, stride length and step length were also significantly improved immediately following the intervention in the VR group.

Mental Practice (MP)
Mental practice can help facilitate motor recovery by activating the same neural circuits that are involved in performing the action. Silva et al. 124 conducted a Cochrane review including 20 RCTs of 762 participants recovering from stroke. Trials compared motor imagery +/- action observation, physical activity, or functional gait training. In most trials, the participants were asked to imagine isolated movements related to gait or to imagine rigorous sports movements. Each session was 30-60 minutes with a total dose of 100 to 1,200 minutes over 2-8 weeks. The control condition was physical therapy in most trials (total dose was 12 to 240 minutes). Mental practice was associated with an increase in gait speed compared with usual care (SMD=0.44, 95% CI 0.06 to 0.81, 6 trials, n=191; GRADE: very low certainty) but not with motor function assessed using the FMA-LE or functional mobility assessed with Rivermead Mobility Index or TUG.

Functional Electrical Stimulation (FES)
FES can be used to improve gait quality in selected patients who are highly motivated and able to walk independently or with minimal assistance A systematic review including the results of 14 trials examined the use of FES applied to the paretic peroneal nerve +/- cointerventions vs. conventional treatment. 125 Peroneal nerve devices were used in 12 trials, with conventional FES devices used in two trials. The stimulation sessions ranged from 20-60 minutes, 1-7x/week, for one day to 30 weeks. FES + supervised exercises was associated with a significant improvement on the 10 Meter Walk Test (10MWT) compared with supervised exercise alone (SMD=0.51, 95% CI 0.16 to 0.86; 5 studies, n= 133) and in TUG (MD = -3.19 sec, 95% CI -5.76 to -0.62; 5 studies, n=780) compared with conventional therapy. A systematic review by Howlett et al.126 included 18 trials of FES for improving upper or lower extremity activity compared to placebo, no treatment or training alone. FES was associated with significantly faster gait speed compared with training alone (MD= 0.08 m/s, 95% CI 0.02 to 0.15; results from 8 trials, 203 participants). However, an older Cochrane review 127 including the results from 24 RCTs, of which 12 evaluated interventions and outcomes associated with mobility. The results suggested that active FES was not associated with significant increases in gait speed (SMD= -0.02, 95% CI -0.30 to 0.26) or stride length (SMD=0.36, 95% CI -0.93 to 1.63).

Biofeedback
Stanton et al.128 included the results of 18 trials evaluating biofeedback. Active interventions included force platforms, EMG biofeedback, audio and visual feedback, provided for an average of 5 weeks. Overall, biofeedback improved lower extremity activities compared with usual therapy (SMD= 0.50, 95% CI 0.30 to 0.70).

Ankle-Foot Orthoses (AFO)
The use of ankle-foot orthoses is widespread. The results from several recent systematic reviews suggest that AFOs can be used to improve mobility and gait parameters. Their use has been associated with significant improvements in TUG, FAC, 6MWT and Motricity Index (MI), compared with no AFO use. 129 Choo & Chang 130 reported significant improvement in cadence, step length and stride length in a systematic review of 19 trials, including 434 participants in the subacute or chronic stage post stroke. An older Cochrane review conducted by Tyson & Kent 131 included the results from 13 RCTs. During a single testing session, participants performed significantly better on measures of balance (weight distribution: SMD=0.32, 95% CI -0.52 to -0.11, p=0.003) and mobility (gait speed: MD=0.06 m/s, 95% CI, 0.03 to 0.08, p<0.0001 and stride length: SMD= 0.28, 95% CI 0.05 to 0.51, p=0.02) while wearing an AFO compared with the control condition where an AFO was not worn. There was no significant treatment effects associated with the outcomes of postural sway and timed mobility tests. In 32 chronic stroke survivors who were randomized to wear or not wear an AFO for a period of three months, gait speed was significantly increased as was and Physiological Cost Index (beats/min) in patients who had worn the device.132

Aquatic Exercise
Aquatic exercise was associated with a significant improvement in gait speed, (SMD=−0.45; 95% CI-0.71 to −0.19) and mobility (SMD= −0.43, 95% CI -0.7 to - 0.17) compared with conventional therapy, in a systematic review including the results of 17 RCTs. 133 In another systematic review including the results from 11 RCTs, 134 hydrotherapy was associated with significant improvements in Forward Reach Test (MD= 1.78, 95% C, TUGT (MD=−1.41, 95% CI −2.44 to -0.42), and knee extensor torque (MD= 6.14, 95% CI 0.59-11.7).


Balance Training

Trunk Training
Trunk training exercises can be assed to standard physiotherapy to help improve balance. Thijs et al.45 conducted a Cochrane review including the results from 68 RCTs including 2,585 participants recovering from stroke across the recovery continuum. Trunk training interventions assessed included core-stability training (isometric strengthening of the trunk muscles, n=18 trials)  electrical stimulation that targeted ≥ 1 core trunk muscles (n=7 trials), selective-trunk training aimed at improving selective movements of the upper and lower part of the trunk (n=15 trials), sitting-reaching therapy (n=6 trials), 10° steady-tilted platform (n=2 trials) and weight-shift training (n=4 trials). The median duration of therapy was 4 weeks, providing a median of 600 minutes of total training. The intensity of training ranged from 30 minutes to 2,700 minutes (45 hours). Trials were classified as dose-dependent (n=44) or non-dose dependent (n=20), based on the amount of therapy provided in the control arms. Therapy provided in the control groups was diverse. Trunk training was associated with a significant improvement in standing balance (SMD=0.57, 95% CI 0.35 to 0.79; 11 trials included; GRADE: very low certainty); and walking ability (SMD=0.73, 95% CI 0.52 to 0.94; 11 trials included; GRADE: very low certainty), compared with non-dose-matched therapy. Compared with dose-matched therapy, trunk training was associated with a significant improvement in standing balance (SMD=1.00, 95% CI 0.86 to 1.15; 22 trials included; GRADE: very low certainty) and walking ability (SMD=0.69, 95% CI 0.51 to 0.87; 19 trials included; GRADE: low certainty). Bank et al.135 included the results of 11 RCTs in a systematic review that investigated physiotherapy plus additional therapy (targeted mainly at improving sitting and standing balance). Compared with conventional physiotherapy alone, additional trunk training exercises did not result in significant differences between groups on the Trunk Control test (MD=-1.53, 95%CI -9.37–6.32, p=0.70; 5 studies, n=263), but was associated with significantly higher Trunk Impairment Scale scores (MD=1.70, 0.62–2.78, p=0.007; 4 studies, n=106).

Force Platform with Feedback
A 2004 Cochrane review 136 included 7 RCTs of 246 participants with abnormal weight bearing in the standing position or impaired standing balance following stroke. Trials compared force platform balance training with visual or auditory feedback vs. conventional treatment or other balance training or placebo balance training. Treatment duration ranged from two to 8 weeks. Intensity and frequency of treatment ranged from 20-60 minutes/session and 2-5 days/week. Visual feedback force platform feedback was not associated with significant improvement in either of the primary outcomes, pooling the results from two to three trials (BBS: MD=-1.98, 95% CI -5.55 to 1.59; and TUG: MD=7.31, 95% CI -1.32 to 15.94). Another systematic review 137 included the results from 8 trials of 214 participants recovering from stroke in the subacute and chronic stages. Trials compared visual feedback balance training using commercially available force platforms devices vs. conventional balance training. Treatment duration was two to 8 weeks. In pooled analyses, visual feedback balance training was not associated with significant differences between groups for any of the balance outcomes of interest (postural sway, weight distribution, BBS and TUG).

Aquatic Exercises
The benefit of aquatic exercises or hydrotherapy compared with land-based training for improving measures of balance was assessed in three recent systematic reviews, each including 11, 15 and 17 RCTs. Sessions in all included trials were typically provided for 30 to 60 minutes, two to 5 times per week and lasted for two to 12 weeks. Significantly greater improvements in BBS scores were reported in pooled analyses in two reviews with mean between group differences at the end of treatment of 1.55 and 1.60 points. 134, 138 In the third review, 133, the standardized mean difference in balance scores was 0.72 (95% CI 0.50–0.94).

Tai-Chi
In three recent systematic reviews, improved balance was reported following a course of traditional Chinese exercises or Tai Chi +/- additional rehabilitation therapies, compared with rehabilitation therapies only. The duration of therapy ranged widely from two to 52 weeks. Tai Chi or traditional Chinese exercises were associated with significantly greater improvement in BBS scores with mean differences of 4.87 (95% CI 4.46–5.28), 139 7.67 ( 95% CI 3.44 -11.90), 140 and 2.07 (95% CI 1.52-2.62).141

Balance Training + Motor Imagery
When added to a program of traditional balance training, motor imagery has been shown to improve balance compared with balance training only. Zhao et al. 142 included the results of 23 RCTs including 1,109 participants with motor dysfunction of the lower extremity. In most trials, kinesthetic motor imagery was used, whereby patients perceive their proprioception with the first-person view performing the movement. Motor imagery + conventional rehabilitation was associated with significantly greater improvement in BBS scores, a secondary outcome (MD=6.29, 95% CI 2.82-9.79).

Whole Body Vibration
In two systematic reviews that compared whole-body vibration training (WBVT) + conventional rehabilitation vs. conventional rehabilitation only, the addition of WBVT was associated with significantly greater improvements in BBS scores with between group mean differences of 4.08 (95% CI 2.39-5.76) 143 and 4.23 (95% CI 2.21-6.26) 144 after four to 12 weeks of treatment.


Sit-to-Stand
A Cochrane review 145 included the results of 13 RCTs that examined repetitive sit-to-stand training, exercise training programs that included sit-to-stand training, sitting training and augmented feedback. Compared with usual care/ or no treatment, repetitive sit-to-stand was associated with increased odds of independence in sit-to-stand (OR=4.86, 95% CI 1.43–16.50), although the results from only one trial were included. Active intervention reduced the time needed for sit-to-stand (SMD=-0.34, 95% CI -0.62 to -0.06, n=7 trials), and improved lateral symmetry (SMD=0.85, 95%CI 0.38–1.33, n=5 trials), but did not reduce the risk of falling (OR=0.75, 95% CI 0.46 to 1.22, n=5 trials).

Aerobic Training
An updated Cochrane review 146 included the results from 75 RCTs trials of patients in both the acute and chronic stages of stroke. Interventions were classified as 1) cardiorespiratory training (circuit training, aquatic training, ergometry, and treadmill training, 2) resistance training (using weights, exercise machines, or elastic devices) and 3) mixed training interventions using various combinations of walking, treadmill training, and resistance training, which included combinations of cardiorespiratory and resistance training methods. The control conditions included usual care, no intervention, or a non-exercise intervention. At the end of the intervention, cardiorespiratory training was associated with significant increases in physical fitness, preferred walking speed and walking capacity, and reductions in disability. Increases in muscle strength, preferred walking speed, and improved walking capacity and balance were also associated with resistance training interventions. Both Sandberg et al. 147 and Hornby et al. 148 reported significantly greater improvements in the 6MWT in RCTs associated with aerobic training, compared with conventional rehabilitation in persons with acute and chronic stroke. Gait speed and fastest possible walking speed were also significantly higher in the aerobic training group. 148, 149 Globas et al. 150 reported significant improvements in measures of cardiovascular fitness, walking ability and performance in patients more than 6 months post stroke who had received a progressive graded, high-intensity aerobic treadmill exercise or aerobic cycling exercise, with lower extremity weights.

Pharmacotherapy & Functional Recovery
Selective serotonin reuptake inhibitors (SSRIs) have been investigated as a potential modulator of functional recovery post stroke, in patients both with and without mood disorders post-stroke. Unfortunately, there appears to be increasing evidence that SSRIs do not help to reduce disability or improve independence and may, in fact, be associated with harm. Mead et al. 53 included the results from three large RCTs in a patient-level meta-analysis, which recruited 5,907 patients with persisting focal neurological deficit following acute stroke. All participants were randomized to receive 20 mg fluoxetine daily or placebo for 6 months. Trials included were The Efficacy oF Fluoxetine-a randomisEd Controlled Trial in Stroke (EFFECTS 54), the Assessment oF FluoxetINe In sTroke recovery trial (AFFINITY, 55) and the Fluoxetine Or Control Under Supervision (FOCUS) trial. 56 At 6 months, the distribution of modified Rankin Scale (mRS) scores did not differ significantly between groups (common OR=0.96, 95% CI 0.87 to 1.05; GRADE: high quality). Neither was the distribution of scores significantly different between groups at 12 months (common OR=0.98, 95% CI 0.89 to 1.07). Fluoxetine was associated with a significantly increased frequency of seizures (2.64% vs. 1.8%, p=0.03), falls with injury (6.26% vs 4.51%, p=0∙03), and fractures (3.15% vs 1.39%, p=0.01). In a Cochrane review, Legg et al. 57 included 76 RCTs including 13,029 participants who had suffered a stroke within the previous 12 months. Trials compared a variety of SSRIs vs. placebo. In most trials, patients were recruited in the early stages of stroke. There was no significant difference between groups in measures of disability (SMD=0.0, 95% CI -0.5 to 0.5, 5 trials; GRADE: high), nor was there a better chance of being independent at the end of treatment (RR=0.98, 95% CI 0.93 to 1.03, 5 trials; GRADE: high). SSRIs were associated with significantly higher risks of seizures and bone fractures.


Sex & Gender Considerations

While women are more likely to survive strokes than men, they tend to experience greater disability. Potential reasons for this imbalance may include greater initial stroke severity, higher pre-stroke disability and older age at stroke onset. 58 Data are limited with respect to rehabilitation outcomes with respect to sex. MacDonald et al. 59 used administrative data sets including 20,143 patients and compared sex differences in discharge Functional Independence Measure (FIM) scores from inpatient rehabilitation units in Ontario over a 5-year period. While in unadjusted analysis, women had a lower mean FIM score (94.1 vs. 97.8, p < 0.001), after adjusting for baseline characteristics, the difference was no longer significant. There is some evidence that women are under-represented in stroke rehabilitation clinical trials. In a recent systematic review, 151 examining female recruitment in 1,285 randomized trials investigating lower-extremity rehabilitation interventions, the overall percentage of women included across all trials was 39.4%. The trials included participants across all stages of stroke chronicity, all rehabilitation settings, and intervention types (pharmacological, traditional and nontraditional rehabilitation therapies, and complementary interventions).

Ressources AVC
Section précédente 3. Amplitude des mouvements et spasticité après un AVC Prochaine section 5. Prévention et prise en charge des chutes