Rev Bras Fisiol Exerc 2021;20(4):405-21

doi: 10.33233/rbfex.v20i4.4799

REVISÃO

Efficacy of resisted training in muscle strength and functionality in adult individuals after brain vascular accident: a systematic review of revisions

Eficácia do treinamento resistido na força muscular e funcionalidade em indivíduos adultos após o acidente vascular cerebral: uma revisão sistemática de revisões

 

Ramon Martins Barbosa1,2,3, Larissa Gessilda da Silva Barbosa1,2, Hiago Silva Queiroz1,2, Lais Santos Oliveira1,2, Marivaldo Nascimento da Silva Júnior1,2, Bruno Santiago Silva1,3, Cristiano Oliveira Souza3, Alan Carlos Nery dos Santos1,2

 

1Instituto Mover, Centro Especializado em Fisioterapia, Feira de Santana, Bahia, Brasil

2Universidade Salvador, UNIFACS, Feira de Santana, Bahia, Brasil

3Hospital Municipal de Serrinha, HMS, Bahia, Brasil

 

Received: June 3, 2021; Accepted: July 17, 2021.

Correspondence: Ramon Martins Barbosa, Instituto Mover, Centro Especializado em Fisioterapia, Avenida Getúlio Vargas, 471, Centro, 44075-525 Feira de Santana BA

 

Ramon Martins Barbosa: ramonmartinsbarbosa@hotmail.com  

Larissa Gessilda Silva Barbosa: l_s.b@outlook.com

Hiago Silva Queiroz: queiroz.hiago@hotmail.com

Marivaldo Nascimento da Silva Júnior: marivaldojuniorfisio@gmail.com

Bruno Santiago Silva: brunosantiagosfisio@gmail.com

Lais Oliveira Santos: laisoliveira168@hotmail.com

Cristiano Oliveira Souza: prof.cristiano.souza@gmail.com

Alan Carlos Nery dos Santos: allannery.santos@hotmail.com

 

Abstract

Objective: To summarize systematic reviews that analyzed the effectiveness of resistance training on muscle strength and functionality in adult individuals after stroke. Methods: Systematic review, PROSPERO (CRD42020208823), performed in the following databases: Pubmed, EBSCO, Lilacs, Medline, Portal BVS, Scielo, Cochrane, SPORTDiscus and PEDro. Descriptors: “Resistance Training”, “Stroke” and “Systematic Review”. Included: Systematic reviews; composed of randomized clinical trials and/or controlled intervention studies; which tested resistance training interventions; compared to other neuromuscular interventions, conventional treatment, or simulation or placebo techniques; in adults who have had a stroke, regardless of the stage of the disease; for the outcomes: muscle strength and functionality. Such studies should be available in full. There were no restrictions regarding the language/time of publication of the studies. The risk of bias was assessed using the AMSTAR-2 scale. Results: Identified 139 articles, however, after analysis 10 were included. These were meta-analytic reviews, published between 2009 and 2020. Resistance training interventions were statistically significant for increasing upper and lower limb muscle strength, gains in 1RM, and performance on the 6-minute walk test. Resistance training was not statistically significant for increased activity, maximum gait speed and preferred gait speed. The studies were of high/moderate risk of bias. Conclusion: Although resistance training is statistically significant for increasing muscle strength and performance in the 6-minute walk test, these results do not seem to be clinically relevant. There was no improvement in preferred walking speed and maximum walking speed.

Keywords: resistance training; stroke; muscle strength.

 

Resumo

Objetivo: Sumarizar revisões sistemáticas que analisaram a eficácia do treinamento resistido na força muscular e funcionalidade em indivíduos adultos após o acidente vascular cerebral. Métodos: Revisão sistemática, PROSPERO (CRD42020208823), realizada nas bases: Pubmed, EBSCO, Lilacs, Medline, Portal BVS, Scielo, Cochrane, SPORTDiscus e PEDro. Descritores: “Resistance Training”, “Stroke” e “Systematic Review”. Incluídos: Revisões sistemáticas; compostas por ensaios clínicos randomizados e/ou estudos de intervenção controlados; que testaram intervenções de treinamento resistido; comparado a outras intervenções neuromusculares, tratamento convencional ou técnicas de simulação ou placebo; em adultos que tiveram acidente vascular cerebral, não importando o estágio da doença; para os desfechos: força muscular e funcionalidade. Tais estudos deveriam estar disponíveis na integra. Não foram realizadas restrições quanto ao idioma/tempo de publicação dos estudos. O risco de viés foi avaliado pela escala AMSTAR-2. Resultados: Identificados 139 artigos, contudo, após análise 10 foram incluídos. Esses eram revisões com meta-análise, publicados entre 2009 e 2020. As intervenções de treinamento resistido foram estatisticamente significativas para aumentar a força muscular de membros superiores e inferiores, ganhos em 1RM e desempenho no teste de caminhada de 6 minutos. O treinamento resistido não foi estatisticamente significativo para aumento da atividade, velocidade da marcha máxima e velocidade da marcha preferida. Os estudos eram de alto/moderado risco de viés. Conclusão: Embora o treinamento resistido seja estatisticamente significativo para o aumento da força muscular e desempenho no teste de caminhada de 6 minutos, esses resultados parecem não ser clinicamente relevantes. Não houve melhora na velocidade de marcha preferida e velocidade de marcha máxima.

Palavras-chave: treinamento resistido; acidente vascular cerebral; força muscular.

 

Introduction

 

Stroke is considered a global public health problem, with a prevalence of 80.1 million cases worldwide [1,2,3]. The 2016 Global Burden of Disease Study [3] highlighted that each year, 13.7 million individuals have a stroke in the world and 5.5 million go on to die. This results directly or indirectly in high costs for health care organizations, and its negative impacts on the functional and biopsychosocial aspects of the population affected by this clinical condition should be mentioned [1,2].

Interestingly, 72% of stroke cases are due to metabolic factors, such as systolic blood pressure, and 66% due to behavioral factors, such as smoking and physical inactivity. While this risk attribution information is not new, much of it is modifiable and, when changed, has been shown to reduce the risk of stroke as well as the recurrent event [1]. Another data that draws attention is that stroke and its comorbidities is the second leading cause of disability worldwide, in which 116.4 million individuals persist with disability-adjusted life years [3]. These data are concerning, as 80% of stroke survivors have motor impairment, affecting the face, arm, and leg on one side of the body [4]. Added to this, it is also known that stroke can impact on the reduction of physical fitness, functionality, and functional capacity, thus necessitating strategies aimed at the recovery/rehabilitation of these clinical outcomes [5,6].

 With this in mind, some studies have identified that physical rehabilitation is effective in promoting the recovery of function and mobility after stroke [4,7]. In the same sense, aerobic training alone or combined with resistance training (RT) was effective in improving speed and walking ability in stroke survivors, in acute or chronic stage [8]. As for RT, previous reviews found insufficient evidence for RT in rehabilitation after stroke [8,9,10]. However, some intervention studies have combined RT with other neuromuscular interventions, a fact that makes it difficult to make an accurate statement about its effectiveness. Thus, our study aimed to summarize systematic reviews that analyzed the effectiveness of RT on muscle strength and functionality in adult subjects after stroke, compared to other neuromuscular interventions, to control with placebo interventions or conventional treatment.

 

Methods

 

Study type

 

This is a systematic review composed of systematic reviews, structured and based on the criteria established by the guideline "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) [11], and the methodological guide proposed by Smith et al. [12], to answer the following clinical question: In adult individuals who suffered a stroke, is the RT, when compared to other neuromuscular interventions, conventional treatments or no intervention (simulation/placebo), effective in improving muscle strength and functionality? Study prospectively registered in PROSPERO under opinion CRD420208823.

 

Eligibility criteria

 

We included: 1) systematic reviews; 2) composed of randomized clinical trials and/or controlled intervention studies; 3) that tested interventions of RT; 4) compared to other neuromuscular interventions, conventional treatment or simulation techniques or placebo; 5) in adults who had stroke, regardless of the stage of the disease (acute or chronic); 6) for outcomes such as muscle strength and functionality; 7) such studies should be available in full. There were no restrictions regarding the language and publication time of the studies. On the other hand, the following were excluded: 1) systematic reviews on CA that used mixed protocols with other training modalities (aerobic training); 2) systematic reviews on CA that did not describe the comparison groups of the included studies; 3) systematic reviews that only analyzed the principles related to the prescription of CA; and 4) systematic reviews on CA for the respiratory muscles.

 

Outcome of interest

 

For the study, muscle strength was considered as the ability of a specific muscle or muscle group to exert force against a given resistance [13]. Strength is associated with the ability to perform vigorous movements, such as pushing or lifting. Functionality was considered based on the International Classification of Functioning (ICF), analyzing the components related to body functions and structures, activity, and social participation [14].

 

Search strategy

 

To formulate the search strategies, the PRESS initiative [15] was used, which aims to perform a peer review of the strategies for electronic searches, in order to minimize possible disagreements, increasing sensitivity/specificity. Thus, the searches were performed in the Pubmed/Medline, Cochrane Library, EBSCOhost/SPORTDiscus, PEDro, Portal da BVS/Lilacs and Scielo databases, by two independent authors [R.M.B] and [H.S.Q], between July and September 2020. The descriptors were selected through the Medical Subject Headings (Mesh) and Health Sciences Descriptors (DeCS): "Resistance Training", "Stroke" and "Systematic Review", with their respective synonyms. The Boolean operators [AND], [OR] and [NOT] were used for potential crossings, as described in Chart 1.

 

Chart 1 - Search strategies for the databases (see PDF annexed)

 

Searching with other resources

 

To identify other published, unpublished, or ongoing studies, we consulted [R.M.B and H.S.Q] the PROSPERO database for prospective registration of systematic reviews. Added to this, we queried the grey literature using Google Scholar. We performed direct citation screening of all included studies (and other relevant studies) using Google Scholar (scholar.google.co.uk/) for additional references to relevant studies.

 

Study selection and data extraction

 

The selection of studies was performed by two independent authors [R.M.B] and [H.S.Q], and when there were eventual disagreements, a third reviewer was requested [M.N.S.J]. Thus, titles and abstracts were thoroughly read, so that those that met the above-mentioned eligibility criteria went to the final selection. As shown in Tables I and II, the eligible studies were selected for full-text reading, further evaluation regarding the selection criteria, and data retrieval regarding: 1) author and year of publication of the study; 2) purpose of the study; 3) type of systematic review/quantity of studies included in the review; 4) population (characteristics and exposure); 5) intervention (type of resistance exercise, weekly frequency and duration); 6) control (form of control); 7) methods (measurement of outcomes); 8) outcomes (muscle strength and functionality) and 9) main results obtained by the studies.

The references reviewed and included in this review were analyzed by the second reviewer [H.S.Q], to verify the existence of potential studies not identified in the electronic database searches. Figure 1 summarizes the selection strategies of the studies that comprise the scope of this systematic review.

 

 

Source: Prepared by the authors.

Figure 1 - Flowchart of the selection of studies that comprise the review

 

Risk of bias

 

The quality of each review was evaluated by two independent authors [R.M.B and H.S.Q], using the criteria of methodological evaluation proposed by the AMSTAR - 2 scale [16]. It consists of a checklist composed of 16 items, which can be answered with "Yes", "Partial Yes" or "No", but is not intended to generate a final score. It classifies the review as "High Quality" = Zero or a non-critical weakness: The systematic review provides an accurate and comprehensive summary of the results. "Moderate Quality" = More than one non-critical weakness*: The systematic review has more than one weakness, but no critical flaws. "Low Quality" = One critical failure with or without non-critical weaknesses: The review has one critical flaw and may not provide an accurate and comprehensive summary of available studies, and "Critically Low Quality" = More than one critical flaw with or without non-critical weaknesses: The review has more than one critical flaw and should not be considered to provide an accurate and comprehensive summary of the available studies. This is the review of the validated and frequently used AMSTAR scale.

 

Results

 

The search strategies and the references analyzed by manual search returned a total of 137 articles. However, after reviewer analysis [R.M.B and H.S.Q], 51 were eliminated for duplicity, leaving 86 studies. In another step, after screening based on the eligibility criteria, another 60 studies were excluded. The main reasons for exclusion were: systematic reviews containing protocols of mixed RT, with other training modalities, that did not perform analyses of individual results for each modality, reviews on inspiratory muscle RT, and reviews that aimed to investigate the principles of RT prescription and/or analyze prescription protocols. Finally, ten (10) studies [8,9,10,17,18,19,20,21,22,23] met the eligibility criteria and are summarized in Figure 1.

According to the data presented in Table I, it can be observed that the included studies were published between the years 2009 and 2020, with 100% of the studies being systematic reviews with meta-analysis. In addition, the number of articles included in each review ranged from 5 to 75 studies, totaling 303 primary studies, with more than 90% being RCTs. Of these 303 studies, 121 were specifically about RT, the others were divided into Cardiorespiratory Training (CRT) and Mixed Training (TM). Regarding population characteristics, the sample ranged from 314 to 3,617 adults, totaling 13,828 individuals. Of these 13,828 individuals, 4,555 participated in the studies on RT. Another noteworthy data is the time since stroke, which varied between 8.8 days and 7.7 years, thus the total sample consisted of individuals in acute and chronic stroke stages. In addition, the included studies had the purpose of evaluating the efficacy as well as the effects of RT in individuals who suffered a stroke, based on our outcomes of interest: muscle strength and functionality (upper limb functionality, gait speed, maximum walking speed (MV), preferred walking speed (PWV), total distance walked, and activity of daily living (ADLs).

 

Table I - Characteristics of studies and population (see PDF annexed)

 

In Table II, it can be observed that in 100% of the studies the participants were exposed to RT interventions with the use of free weights and/or weight-training equipment and/or elastic bands. The programs in the intervention group (IG) were applied in sessions of 15 to 90 minutes, 3 to 5 sets of repetitions, 6 to 15 repetitions, with intensity varying: 50-100% of body weight, 25-85% of 1RM, 40-70% of maximum strength, and 7-15 maximum repetitions, 2 to 5 days a week, during a period of 3 to 19 weeks. Furthermore, when the comparison methods were analyzed, the most commonly used were: conventional functional training, stretching, range of motion (ROM) exercises, RCT, TM, usual care, placebo, and no intervention. Outcomes such as muscle strength, and functionality (gait, upper limb function, gait speed, MV, MVP, total distance walked and ADLs) were evaluated, by means of clearly described methods such as: 1RM, dynamometry, 6-minute walk test (6MWT), Timed Up and Go (TUG) and the Fugl-Meyer scale.

 

Table II - Summary of the evaluation process, intervention, outcomes, and main results of the reviewed studies (see PDF annexed)

 

The main results of the studies analyzed by the present review indicate that the RT interventions were statistically significant for the increase in upper and lower limb muscle strength, gains in 1RM and performance in the 6MWT. RT was not statistically significant for increases in ADLs, MVM and MPV.

Regarding the methodological quality (Table III), 50% of the studies were of high methodological quality. The other 50% were composed of moderate quality studies. The most critical point was with respect to the source of financing of the studies included in the analyzed reviews, only one study declared the information.

 

Table III - Methodological quality, AMSTAR-2        

 

X = Yes; / = Partial Yes. 1. The research questions and inclusion criteria for the review included the components of PICO; 2. The review report contained an explicit statement that the review methods were established prior to conducting the review and the report justified any significant deviations from the protocol; 3. The review authors explained their selection of study designs for inclusion in the review; 4. The review authors used a comprehensive literature search strategy; 5. The review authors performed duplicate study selection; 6. The review authors performed duplicate data extraction; 7. The review authors provided a list of excluded studies and justified the exclusions; 8. The review authors described the included studies in adequate detail; 9. The review authors used a satisfactory technique to assess risk of bias (RoB) in individual studies that were included in the review; 10. The review authors reported the funding sources for the studies included in the review; 11. If a meta-analysis was performed, the review authors used appropriate methods for statistical combination of results; 12. If a meta-analysis was performed, the review authors assessed the potential impact of RoB in individual studies on the results of the meta-analysis or other synthesis of evidence; 13. The review authors took RoB in individual studies into account when interpreting / discussing the review results; 14. Review authors provided a satisfactory explanation for, and discussion of, any heterogeneity observed in the review results; 15. If they performed a quantitative synthesis, review authors performed an adequate investigation of publication bias (small study bias) and discussed its likely impact on the review results; 16. The review authors reported any potential sources of conflict of interest, including any funding they received to conduct the review

 

Discussion

 

In response to the objectives of this systematic review, it was identified that when compared to other neuromuscular interventions, conventional treatment or simulation techniques, or placebo, RT is statistically significant for improvement in upper and lower limb muscle strength, gains in 1RM, and performance on the 6MWT. In addition, RT was not statistically significant for improvement in ADLs, MVM and MPV. It is also noteworthy that when compared to other interventions such as RCT and MT, RT was not statistically significant for improvement in MVM, MPV and 6MWT performance. The results presented here are reinforced by the high/moderate methodological quality of the included reviews.

Regarding muscle strength and gains in 1RM, the included studies suggest that there was a statistically significant increase in individuals who performed RT [8,18,19,20,21,22,23]. However, these results may not be clinically important. In fact, Lang et al. [24] suggest that a clinically important change in grip muscle strength for upper limbs of stroke survivors was 5.0 kg and 6.2 kg for the dominant and non-dominant affected sides, respectively. In addition, Aguiar et al. [25] suggest that for a change in muscle strength to be considered relevant after an intervention assessed by dynamometry, in individuals who have suffered a stroke, one should have variations equal to or greater than 0.96 kg to 6.12 kg. However, although the included studies suggest that RT increases the FM, the data on strength gains are not presented for analysis, a fact that limits the comparison/extrapolation of the data.

Added to the data already presented, the RT was not statistically significant for the improvement of ADLs [18,21]. This result can be justified by the fact that the RT did not incorporate the performance of the specific task at the moment of the exercise execution. Another point is that even though RT promotes a statistically significant gain in strength, it may not be transferred to the performance of activities [21]. Furthermore, a change in strength and activity is related to the amount of baseline strength, and in individuals who have a decrease in strength, any increase in strength produces a large increase in activity. However, in individuals with reasonable strength, an increase in strength does not produce much change in activity.

Moreover, when the gait-related variables were analyzed, the RT benefited only the performance at 6MWT, with no significant improvement for MV and MVP [8,17,19,20,22]. Thus, RT may promote some intramuscular metabolic adaptations, increasing participants' performance tolerance when performing the 6MWT [22,26]. However, there is little certainty of the evidence for this result. Another point is also that although the 6MWT showed a significant effect, these results may not be clinically relevant. In fact, Fulk et al. [27] suggested that the minimum clinically important difference for TC6m is +71 to +130 m, based on patients who initially walk fast (≥ 0.4 m/sec). Added to this, Fulk et al. [28] concluded that a clinically important increase in MPV after stroke would be 10.5 m/minute. Thus, it is evident that gait speed at baseline will be an important consideration in making judgments about the magnitude of effects related to walking speed outcomes [22].

Another interesting finding is that when compared to RCT and MT, RT was not statistically significant for improvement in MV, MVP, and 6MWT [8,19,20,22]. Thus, the studies suggest that the improvement in these variables when performing RCT and MT can be justified by the fact that these training modalities promote a greater reserve of cardiorespiratory fitness, which can be related to an increased VO2 peak, considering that, in individuals who suffered a stroke, the cardiorespiratory fitness is reduced by 30-70% when compared to their healthy peers [22,29]. Still, walk-based training interventions dominate the RCT and TM protocols and these are, by definition, task-related and repetitive in nature. Thus, these elements alone may facilitate motor learning and benefit gait performance.

Finally, this study has some limitations that need to be discussed. First, most of the included reviews did not report the percentage of the population in acute or chronic stage of stroke, a fact that limits the interpretation/generalization of the findings for each specific subgroup. Second, not all included studies showed which criteria were used to define what they considered as a RT, a fact that limits the analysis and interpretation of the data. Another point is also in relation to the tools for measuring the outcomes, since they did not always evaluate the same functional domain, and some tools were not validated for individuals who suffered a stroke. In addition, most of the studies included in the reviews were performed with short-term protocols, which limits the interpretation of what the long-term benefits are. Furthermore, about the methodological quality of the studies included in the reviews, the vast majority had moderate/high risk of bias. Finally, the quality of evidence of most studies included in the reviews was of moderate quality, which shows that the true effect is close to the estimated effect, but that there is the possibility of it being substantially different. However, these limitations do not invalidate the data presented, since they are in line with others presented in the literature.

 

Conclusion

 

It was concluded that when compared to other neuromuscular interventions, conventional treatment or simulation techniques, or placebo, RT is effective in improving upper and lower limb muscle strength, gains in 1RM, and performance on the 6MWT. However, these findings do not seem to modify clinical practice, since the results were not presented as clinically relevant. Furthermore, RT was not statistically significant for improvement in activity, MVM and MPV. Nor when compared to other interventions such as RCT and MT, for improvement of MVM, MPV and performance on 6MWT.

 

Potential conflict of interest

No potential conflicts of interest relevant to this article have been reported

 

Funding sources

There were no external funding sources for this study

 

Authors' contribution

Conception and design of research: Barbosa RM, Santos ACN, Barbosa LGS, Queiroz HS. Acquisition of data: Barbosa RM, Santos ACN, Queiroz HS, Júnior MNS, Silva BS. Analysis and interpretation of the data: Barbosa RM, Santos ACN, Barbosa LGS, Souza CO, Oliveira LS, Queiroz HS. Statistical analysis: Barbosa RM, Santos ACN, Souza CO. Obtaining financing: Not applicable. Writing of the manuscript: Barbosa RM, Santos ACN, Barbosa LGS, Oliveira LS. Critical revision for intellectual content: Barbosa RM, Santos ACN, Souza CO, Silva BS, Queiroz BS, Júnior MNS.

 

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