Table 2.

Clinical trials investigating graded muscle strengthening programs in individuals with stroke

Authors, Study Design, and Evidence Level	Subjects	Intervention	Results
LOWER EXREMITY
INPATIENT REHAB
Moreland et al,57 2003 RCT Level I	133 subjects (multi-centre), < 6 months post-stroke	Inpatient conventional physical therapy versus conventional + resistive exercises with weights, 30 minutes, 3X/week.	No difference in 2 minute walk test or Disability Inventory
Inaba et al,58 1973 RCT Level II (high error risk, large number of drop-outs)	77 subjects, < 4 months post-stroke, non-ambulatory	1 to 2 months, daily 1. functional training and stretching (n=26) (control) 2. control activities plus active exercise (n=23) 3. control activities plus resistive exercise (n=28)	Greater improvement of 10 Repetition Maximum strength and activities of daily living for group 3 (resistive group) after 1 month. No group differences after 2 months training, but it does not appear that all subjects underwent 2 months training.
Glasser,59 1986 Small RCT Level II	20 subjects, 3–6 months post-stroke	5 week inpatient physical therapy (5X week, 2 one hour sessions/day) (n=10) versus physical therapy plus kinetron isokinetic LE exercise (n=10) (resisted reciprocal hip/knee flexion during semi-sitting posture progressed from 10–30 minutes over the 5 weeks).	No differences in functional ambulation profile (includes temporal and distance gait variables)
Badics et al,60 2002 Pre-test/post-test Level V	56 subjects, 3 weeks to 10 years post-stroke	Residential rehabilitation which included leg extensor presses, arm presses (triceps) at 30–50% MVC, 3–5 sets of 20 repetitions. Other activities not documented. 20 subjects did not do the arm program due to severe arm conditions.	31%↑ in LE strength and 37%↑ in UE strength.
OUTPATIENT OR COMMUNITY
Kim et al,61 2001 Small RCT Level II	20 ambulatory subjects, > 1 year post-stroke	6 week passive exercise (n=10) versus isokinetic paretic strengthening (hip, knee, ankle) (n=10).	Trend, p < 0.06 for ↑ isokinetic torque (of strength group over control No group differences in gait or stair speed.
Carr and Jones,62 2003 RCT Level II (high error risk, e.g., 200% baseline group differences for some strength measures and no co-variates considered. Drop-outs occurred, but their numbers not reported)	40 subjects, > 6 months post-stroke	16 week aerobic (recumbent bike with arm ergometer) versus aerobic + arm/leg graded strength training (free weights and isokinetic machines), 3X week.	Both groups ↑ knee flexion torque and shoulder extension, but not knee extension. Only strength+aerobic group↑ shoulder flexion.
Bourbonnais et al,63 2002 Small RCT Pre-test/post-test/8 week retention Level II	25 subjects with chronic stroke	6 week, 3X week, visual feedback of multi-joint, multi-directional isometric force generation (coordination exercises). UE (n=13): varying combinations of shoulder, elbow, and grip forces (progress from 20–60% MVC). LE (n=12): varying combinations of hip, knee and ankle forces (40–90% MVC).	UE group had 35% ↑ in UE isometric force. No group difference for UE Fugl-Meyer, dexterity, finger-to-nose test. LE group had 55% ↑ in LE isometric force. LE group had 25% greater improvement in gait speed over UE. No change in Timed up and Go Test for either group.
Engardt et al,64 1995 Stratified non-random allocation Level III Note: no actual control for effect of strength and could be considered Level V for this variable	20 ambulatory subjects with chronic stroke	6 week, 2X week, isokinetic eccentric (n=10) or concentric (n=10) paretic knee extensor strengthening.	Both groups ↑ knee eccentric and concentric torque but no group differences. Eccentric has ↑ in eccentric and concentric torque relative to the non-paretic leg, but concentric did not. ↑ symmetrical forces during rise up from chair with eccentric training only. No group differences for gait speed. ↑ Antagonist EMG activity with concentric but not eccentric training.
Weiss et al,65 2000 Pre-test/post-test Level V	7 subjects with chronic stroke	12 week, 2X/week resistance training for both LEs (leg press, knee extension, hip motions) at 70% 1 Repetition Maximum.	68% ↑ on paretic and 48% ↑ on non-paretic for five leg muscle groups. 21%↓ on rise from chair time. No change gait speed. ↑ Motor Assessment Scale (lower limb score). ↑ Berg balance score by 5 points.
Sharp and Brouwer,4 1997 Pre-test, post-test, 1 month retention Level V	15 ambulatory subjects, > 6 months post-stroke	6 week, 3X/week, 40 minutes/day isokinetic paretic knee strengthening.	15–20% ↑ paretic knee extension and 37–39%↑ flexor torque post-intervention. Only 1 of 6 muscle tests (30 degrees/second, quads) were significant at retention. 5.3% ↑ gait velocity post-test and 6.8% ↑ at retention. No change Timed up and Go or stair ability ↑ level of physical activity (Human Activity Profile).
UPPER EXTREMITY
Bütefisch et al,66 1995 Multiple baseline RCT Level II	27 subjects 3–19 weeks post-stroke with minimal to mild UE deficits 1–4 week intervention	Group 1: Strength group, 2X day, 15 min each session, in addition to standard inpatient therapy (n=12) (grip exercises, isotonic wrist extension against weights, resisted finger extension. Group 2: 2 weeks TENS group (n=15), followed by strength program	↑ grip strength, isometric hand extension force, acceleration of hand extension and Rivermead Motor Assessment (arm section) for both groups following strength training period.
Trombly et al,67 1986 Level II	20 subjects, average 6 weeks post-stroke and could grasp a 2.5 cm cylinder	All received typical rehabilitation (including occupational therapy) plus the following treatments (one set of 10 repetitions) daily for a max of 20 sessions: Group 1: Control (n=5) Group 2: Resisted finger extensions (n=5) Group 3: Ballistic finger extensions (n=5) Group 4: Resisted grasp (n=5)	No group differences in finger or hand function. Note: underpowered sample with baseline group differences in hand function.
Bourbonnais et al,63 2002 (see above in LE section)