Review question
We reviewed the evidence about the effect of interventions aimed at improving community ambulation in adult stroke survivors.
Background
We wanted to determine whether programmes aimed at improving community ambulation for stroke survivors were better or worse than usual treatment. Community ambulation refers to the ability of a person to walk in their own community, outside of their home and also indoors, in private or public locations. Some people choose to walk for exercise or leisure and may walk with others as an important aspect of social functioning. Community ambulation is therefore an important skill for many stroke survivors living in the community whose walking ability has been affected.
Study characteristics
The evidence in this review is current to November 2013. We included five studies with a total of 266 participants. All participants were adult stroke survivors who lived in the community or a care home. Programmes to improve community ambulation consisted of walking practice in a variety of settings and environments in the community (three studies), or an activity indoors that mimicked community walking (three studies). Three studies were funded by government agencies, and two had no funding.
Key results
The term 'participation' refers to the ability of a person to engage in activities that are meaningful to them, such as leisure activities, paid or volunteer work, or socialising with others. For the primary outcome of participation we could not be sure whether the intervention improved participation compared with control (two studies). When considering how fast a person walks, it is unclear if the speed of walking may increase with a community ambulation intervention ( four studies). Based on the included studies, the effect of the intervention on the ability to walk, how far people could walk in six minutes or their confidence in walking is unclear. There is currently insufficient evidence to establish the effect of community ambulation interventions or to support a change in clinical practice. No adverse effects of the interventions were reported in any of the included studies.
Quality of the evidence
We considered the quality of the evidence to be low across the studies for both the participation and walking speed outcomes. There were some study design considerations which led to the low score, such as who knew what group the participants were in, and the number of people who dropped out of the studies. Also, we included a small number of studies in this review, which limits how the results can be interpreted. More research is needed in this area.
There is currently insufficient evidence to establish the effect of community ambulation interventions or to support a change in clinical practice. More research is needed to determine if practicing outdoor or community walking will improve participation and community ambulation skills for stroke survivors living in the community.
Community ambulation refers to the ability of a person to walk in their own community, outside of their home and also indoors in private or public locations. Some people choose to walk for exercise or leisure and may walk with others as an important aspect of social functioning. Community ambulation is therefore an important skill for stroke survivors living in the community whose walking ability has been affected.
To determine: (1) whether interventions improve community ambulation for stroke survivors, and (2) if any specific intervention method improves community ambulation more than other interventions.
We searched the Cochrane Stroke Group Trials Register (September 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (November 2013), PubMed (1946 to November 2013), EMBASE (1980 to November 2013), CINAHL (1982 to November 2013), PsycINFO (1887 to November 2013), Scopus (1960 to November 2013), Web of Science (1900 to November 2013), SPORTDiscus (1975 to November 2013), and PEDro, CIRRIE and REHABDATA (November 2013). We also searched ongoing trials registers (November 2013) and reference lists, and performed a cited reference search.
Selection criteria included parallel-group randomised controlled trials (RCTs) and cross-over RCTs, studies in which participants are adult (aged 18 years or more) stroke survivors, and interventions that were aimed at improving community ambulation. We defined the primary outcome as participation; secondary outcomes included activity level outcomes related to gait and self-efficacy.
One review author independently screened titles. Two review authors screened abstracts and full text articles, with a third review author was available to resolve any disagreements. Two review authors extracted data and assessed risk of bias. All outcomes were continuous. The analysis for the primary outcome used the generic inverse variance methods for meta-analysis, using the standardised mean difference (SMD) and standard error (SE) from the participation outcomes. Analyses for secondary outcomes all used SMD or mean difference (MD). We completed analyses for each outcome with all studies, and by type of community ambulation intervention (community or outdoor ambulation practice, virtual practice, and imagery practice). We considered trials for each outcome to be of low quality due to some trial design considerations, such as who knew what group the participants were in, and the number of people who dropped out of the studies.
We included five studies involving 266 participants (136 intervention; 130 control). All participants were adult stroke survivors, living in the community or a care home. Programmes to improve community ambulation consisted of walking practice in a variety of settings and environments in the community, or an indoor activity that mimicked community walking (including virtual reality or mental imagery). Three studies were funded by government agencies, and two had no funding.
From two studies of 198 people there was low quality evidence for the effect of intervention on participation compared with control (SMD, 0.08, 95% confidence interval (CI) -0.20 to 0.35 (using inverse variance). The CI for the effect of the intervention on gait speed was wide and does not exclude no difference (MD 0.12, 95% CI -0.01 to 0.24; four studies, 98 participants, low quality evidence). We considered the quality of the evidence to be low for all the remaining outcomes in our review: Community Walk Test (MD -6.35, 95% CI -21.59 to 8.88); Walking Ability Questionnaire (MD 0.53, 95% CI -5.59 to 6.66); Six-Minute Walk Test (MD 39.62 metres, 95% CI -8.26 to 87.51) and self-efficacy (SMD 0.32, 95% CI -0.09 to 0.72). We downgraded the quality of the evidence because of a high risk of bias and imprecision.