Vol.1, No.2, 40-51 (2013) Open Journal of Therapy and Rehabilitation
Action for Rehabilitation from Neurological Injury
(ARNI): A pragmatic study of functional training for
stroke survivors
Cherry Kilbride1, Meriel Norris1, Nicola Theis2, Amir A. Mohagheghi2*
1Centre for Research in Rehabilitation, School of Health Sciences and Social Care, Brunel University, London, UK
2Centre for Sports Medicine and Human Performance , School of Sport and Education, Brunel University, London, UK;
*Corresponding Author: amir.mohagheghi@brunel.ac.uk
Received 5 June 2013; revised 8 July 2013; accepted 20 July 2013
Copyright © 2013 Cherry Kilbride et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
This study evaluated the effectiveness of a
twelve-week community-based functional train-
ing on measures of impairment, activity and par-
ticipation in a group of stroke survivors. Isome-
tric strength of the knee musculature , Centre-O f-
Pressure (COP) based measures of balance,
Berg Balance Scale (BBS), 10 m walk test, and
the Subjective Index of Physical and Social Out
come (SIPSO), were recorded at baseline, post-
intervention, and after twelve weeks (follow-up).
Exercise instructors delivered training once a
week in a group format at a community centre.
Significant improvement was noted in the BBS
(p < 0.002), and 10 m walk speed (p = 0.03) post
intervention which remained unchanged at fol-
low-up. Total SIPSO score improved signifi-
cantly post-intervention (p = 0.044). No other
significant differences and no adverse effects
were observed. It is possible that functional
training provided more opportunity for the im-
provement of dynamic aspects of balance con-
trol that could be captured by the BBS but not
with the traditional measures of balance using
COP data. Results also suggest positive effects
on the level of participation, and lack of asso-
ciation between measures of impairment and
activity. Community based functional training
could be effective and used to extend access to
rehabilitation services beyond the acute and
sub-acute stages after st ro ke.
Keywords: Balance; Centre-of-Pressure;
Functional Training; Hemiplegia; ICF;
Rehabilitation; Strength; Stroke
Stroke is the single biggest cause of severe adult dis-
ability in the UK [1], and affects between 178 and 317
people per 100,000 population in England each year [2].
One in four men and one in five women aged 45 and
over will have a stroke during their lifetime [3] with a
quarter of new strokes being in those aged under 65 [1].
Stroke therefore represents a sizeable challenge on mul-
tiple levels. At the societal level, stroke is estimated to
cost in the region of £2.8 billion per annum in the UK
[2,4]. On a personal level, the “costs” are arguably
greater; while one third of people who have a stroke fully
recover, a third die, with the remaining third having to
contend with residual motor and sensory abnormalities,
many of whom also have associated psychological
side-effects [5,6]. More specifically, stroke can result in
impairments such as the loss of muscle strength [7-13],
and dexterity and proprioception [14,15]. Additionally,
postural steadiness (the ability to maintain balance dur-
ing dynamic and static activities) is often reduced [16,
17]. As balance is an integral part of everyday function-
ing, alterations in this modality can have a detrimental
effect on many aspects of a person’s life including their
ability to walk [18,19].
Currently rehabilitation post stroke is predominantly
limited to the acute and sub-acute stages with limited
access beyond 6 months [20,21]. However evidence sug-
gests that functional recovery can continue beyond six
months, with the recovery plateau post stroke being
strongly debated in the literature [22-24]. Yet how on-
going rehabilitation can be achieved presents a challenge
given that current access to community-based therapies,
in particular physiotherapy, has been described by stroke
survivors as being too brief and time limited to promote
best recovery [25,26].
Copyright © 2013 SciRes. OPEN ACCESS
C. Kilbride et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 40-51 41
The need to develop strategies for accessing further
rehabilitation beyond the current NHS pathways is evi-
dent. Delivery of health and well-being interventions by
non-healthcare professionals is not without precedence
and is a growing area of interest [27-29]. For example,
people living with cardiovascular conditions in the com-
munity are commonly referred to exercise groups run by
professional fitness instructors [30]. Similarly more pro-
vision for the continuing input for stroke survivors from
outside the health system is being seen, and the evidence
for community based exercise after stroke schemes is
growing and highlighted in policy and clinical stroke
guidelines for further development [20,31,32].
Action for Rehabilitation from Neurological Injury
(ARNI) is a UK based charity founded in 2001 by a
stroke survivor which aims to help bridge this gap by
providing functional training for people with stroke. The
service is delivered by ARNI accredited exercise in-
structors (non-medical) and is focused on the achieve-
ment of functionally-oriented tasks through improving
strength, endurance, balance and coordination, and mo-
tivation as described in the ARNI manual and a two day
training programme [33]. ARNI training is a multimodal
approach of which functional strength training is one
component. For example, participants in the group for-
mat may practice sit to stand to strengthen hip and knee
extensors. Consequently, improvement in strength is ex-
pected as a benefit of ARNI training. ARNI is mostly
delivered on a one to one basis as opposed to a group
format, although in service delivery models (e.g. Bed-
fordshire and Hertfordshire), a group format has been
adopted which is a decision mostly driven by financial
and personnel constraints [34]. While there are numerous
personal testimonies to the success of the approach for
individual stroke survivors [35], to date there is no em-
pirical evidence of outcomes and uncertainty remains as
to the effects of this training programme.
The aim of this 16 month pragmatic study was to eva-
luate the effectiveness and acceptability of ARNI func-
tional training programme for people with stroke using a
group model for service delivery. Findings from a quali-
tative evaluation relating to the acceptability of taking
part in the ARNI training programme are reported else-
where (Norris et al.—in press). This paper specifically
reports the effectiveness of training based on data from a
range of biomechanical, physical and psychosocial
measures. Reported results can be used for the calcula-
tion of sample size in future larger studies, and provide
insight into the potential obstacles of service delivery.
A pragmatic mixed methods approach was used. The
intervention provided was a 12 week, 1 1/2 hour weekly
group based ARNI programme [33]. Training was deliv-
ered by two exercise instructors to a maximum of 8 par-
ticipants to ensure safety and to maximise the opportu-
nity for individuals to have some 1:1 time with an in-
structor (whilst the remaining people continued exercis-
ing as part of the group) to address personal goals. In
total, four groups completed the training programme,
which is described in detail elsewhere [33]. The pro-
gramme took place in a newly built leisure centre facility
in West London, UK.
In line with the International Classification of Func-
tioning, Disability, and Health (ICF) levels, impairment
was assessed by biomechanical tests of strength and
postural steadiness and activity was measured through
the use of the Berg Balance Scale (BBS) and 10 m walk.
The validated Patient Reported Outcome Measure,
SIPSO, was used as a measure of both social and physi-
cal impact acting as an indicator of participation [36].
2.1. Participants
All participants who volunteered to take part in the
study were community dwelling stroke survivors who
had finished formal physical rehabilitation. Participants
in the study were screened and referred by a physio-
therapist and all received GP clearance before taking part
in the training. In total 30 stroke survivors participated in
the intervention. Thirteen participants (4 F, 9 M, mean
age 53 years; range 19 - 80 years; average time post
stroke 20 months; range 4 - 154 months) volunteered to
Table 1. Anthropometric data of participants.
1 M 684 46 R 12
2 M 733 32 R 154
3 F 752 19 R 7
4 M 732 63 L 11
5 F 730 58 L 7
6 F 585 52 R 8
7 M 817 33 R 17
8 M 1040 48 L 13
9 M 877 76 R 4
10 F 612 49 R 12
11 M 890 80 R 6
12 M 528 56 L 5
13 M 831 76 R 4
Note. Side refers to the paretic side: R = right, L = left.
Copyright © 2013 SciRes. OPEN ACCESS
C. Kilbride et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 40-51
Copyright © 2013 SciRes.
complete various aspects of the impairment and activity
testing, which had an inclusion criteria of independent
standing balance for a minimum of 2 minutes and the
cognitive ability to follow simple instructions required
for the strength tests (Table 1).
The SIPSO which was open to all participants was
completed by 23 participants who equally had a diverse
profile in terms of age and time since stroke. Figure 1
presents a flow chart of assessments completed and num-
ber of participants at each stage whose data contributed
to the results and analyses including withdrawals and
reasons for non-completion. Demographics of partici-
pants who took part in the ARNI training are presented
in Table 2. Ethics approval for the conduction of the
study was obtained from the Brunel University School of
Sport and Education Research Ethics Committee, and all
participants provided informed consent before taking
part in the study.
n = 4 did not
respond to
Completed clinical
and lab testing
(n = 11)
n = 7 did not
respond to
n = 3 did not
meet testing
requirement for
clinical testing
n = 4 did not
meet testing
requirement for
lab based
n = 2 because
of medical
condition, n = 1
n = 2 unable to
attend, n = 1
ecause of illness
Completed focus
(n = 22)
n = 2 unable
to attend on
Completed SIPSO
(n = 19)
Completed clinical
and lab testing at 3
months follow up
(n = 8)
Volunteered for
focus group
(n = 24)
Completed SIPSO at
3 months follow up
(n = 12)
Completed SIPSO
(n = 23)
Completed clinical testing
pre-training (n = 14)
Lab based measures
(n = 13)
Volunteered for
physical testing
(n = 17)
Volunteered for
research arm
(n = 25)
Accepted onto
training programme
(n = 30)
Volunteered for
(n = 23)
Did not volunteer
for research arm
(n = 5)
Figure 1. Flowchart of assessments completed and participation at each stage of the study.
Table 2. Demographic data of participants in the ARNI training.
Characteristic Totals/Average (range) Physical testing SIPSO Focus Groups
Participants 25 14 23 22
Gender 9 F, 16 M 4 F, 10 M 9 F, 13 M 8 F, 13 M
Age (years) 61.6 (19 - 84) 61.6 (19 - 82) 61.6 (19 - 84) 61.6 (19 - 84)
Time since stroke (years) 3.18 (0.5 - 26) 1.71 (0.5 - 13) 2.23 (0.5 - 26) 1.67 (0.5 - 13)
No.te Physical testing refers to both clinical and lab based measures.
C. Kilbride et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 40-51 43
2.2. Procedure
All measures were taken at baseline, post intervention
and at 3 month follow-up and were repeated in the same
order. They were conducted by the same researchers to
maintain consistency.
For the tests of postural stability, the participant was
asked to stand comfortably on a Kistler piezoelectric
force platform (type 9281B11; Kistler, Switzerland);
arms by their side, while maintaining their gaze on a
(black circle) target mounted on a wall in front of them at
three meters distance, and keep this position for 30 sec-
onds. No instruction with respect to the foot placement
was provided. Coordinates of the centre of pressure
(COP) in the anteroposterior (AP) and mediolateral (ML)
directions recorded during the last 20 seconds of quiet
standing were used to calculate eight measures of pos-
tural steadiness (total, AP, and ML excursions of the
COP; total, AP, and ML velocity of the COP; AP and
ML range of COP excursion) according to Prieto et al.
[37]. A maximum of three successful trials were col-
lected based on the participant’s ability to maintain their
balance or follow the instructions for the duration of the
trial and the average of the outcome measures were used
in the analysis. The participant sat down between trials
for thirty seconds to avoid fatigue.
It was decided to test the strength of the knee flexor
and extensor muscle groups as an indicator of strength in
the lower limb since a significant correlation amongst
strength measured from different muscle groups of the
lower limb after stroke has been reported [38,39]. A
System 3 Biodex Isokinetic Dynamometry system (Bio-
dex Medical Systems, New York, USA) was used for the
assessment of strength of both the non-paretic (NP) and
paretic (P) sides. The non-paretic limb was tested first.
The participants were asked to produce maximum iso-
metric knee extension or flexion torques while in a
seated position (back rest angle at 85 degrees) at two
different joint angles equal to 90% and 80% of the
available range of motion between 90 degree of knee
flexion and full extension. Using this procedure, torques
were measured at angles closer to full knee extension.
The order of angle at which strength was tested was al-
ternated between the participants. Verbal encouragement
was provided during the trials.
At each joint angle tested, the participant was asked to
produce a maximum extension torque for five seconds
followed by a maximum flexion torque for five seconds.
There was a ten second rest interval between each exten-
sion-flexion torque pair. Three pairs of extension-flexion
torques were produced at each joint angle. There was
120 seconds rest interval between the sets of exten-
sion-flexion torque production at the two angles. Maxi-
mum torques recorded during the last two pairs of torque
production were normalised to the body weight [40,41]
and their average was used in the final analysis. Some
participants were unable to produce torques above the
value used by the system for gravity correction. For these
individuals/sessions the gravity correction value deter-
mined by the system at the time of testing was used as
the maximum torque to prevent missing values for the
analysis. Accordingly, maximum torque could have been
overestimated in such circumstances. Dynamometry and
force platform data were sampled at 100 Hz.
The Berg Balance [42] was carried out in accordance
with published guidelines. The 10 m walk was repeated
three times with a one metre lead in and out distance.
The average of the three trials was calculated and the
participant was given the option to rest between trials to
minimise the impact of fatigue. The SIPSO was com-
pleted independently by the participants.
2.3. Data Analysis
Clinical data were analysed in SPSS (SPSS Inc.; ver.
18.02) using a variety of tests as appropriate including
t-test, ANOVA, related samples Friedman’s Two-way
analysis of variance or a one tail sign test. For the bio-
mechanical data, conventional paired t-test, one-way
ANOVA, and MANOVA with repeated measures (side,
joint angle, and testing session) was used to test the ef-
fect of training on balance and strength data between the
NP and P sides at baseline and post-training, or across
the three (baseline and post-training and follow up)
testing sessions at the two joint angles. The level of sig-
nificance for all tests was selected at 0.05 (α = 0.05). An
intention to treat analysis was conducted. Attendance
rate was good averaging 74% - 90% across the four
Different number of participants took part in different
tests. Figure 1 illustrates a flow chart of the study where
reasons for drop outs are also included.
3.1. Measures of Impairment
Overall, postural stability performance of the partici-
pants did not show any statistically significant differ-
ences across the three sessions, or between the baseline
and post-training sessions (all p values > 0.05). Results for
the postural steadiness are illustrated in Figures 2 and 3.
For the extension torque at the baseline and post-
training sessions, the effects of side and joint angle were
significant. As expected, the non-paretic (NP) legs were
significantly stronger than the paretic (P) legs (F[1,10] =
19.98; p = 0.001), and the torques produced at the rela-
tively more extended joint angle were smaller (F[1,10] =
44.61; p = 0.0001). For the flexion torque, only the effect
of side was significant where NP legs produced higher
flexion torque values compared to the P legs (F[1,10] =
Copyright © 2013 SciRes. OPEN ACCESS
C. Kilbride et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 40-51
COP Excursion (m)
Figure 2. MLEX = excursion of the centre of pressure (COP)
in the mediolateral (side-to-side) direction; APEX = excursion
of the COP in the anteroposterior (forward-backward) direction;
TOTEX = total excursion of the COP. Error bars are group
standard deviations. PRE, POST, and FOL refer to the pre-,
post- and follow-up testing sessions.
Figure 3. R ML = range of COP excursion in the mediolateral
direction (m); R AP = range of COP excursion in the antero-
posterior direction (m); M VEL ML = mean velocity of the
COP in the ML direction (m/s); M VEL AP = mean velocity of
the COP in the AP direction (m/s); M VEL = mean velocity of
the COP (m/s); Error bars are group standard deviations. PRE,
POST, and FOL refer to the pre-, post- and follow-up testing
9.26; p = 0.012). Similar results were found when the
extension torques results were analysed across three ses-
sions (F[1,7] = 24.15; p = 0.002 for the effect of side, and
(F[1,7] = 54.60; p = 0.0001 for the effect of joint angle),
but the difference between the NP and P sides for the
flexion torques became non-significant (Figures 4 and 5).
3.2. Measures of Activity
Results for the measures of activity are shown in Ta-
ble 3. Balance as measured by the BBS indicated a sig-
nificant improvement across the testing sessions (F[2,11] =
10.63; p < 0.002) and all participants improved their
scores. The average change from baseline to follow-up
sessions was 6 points. This exceeded the minimal de-
tectable change (MDC) for chronic stroke (defined as >6
months post stroke) which was reported as 2.5 points on
the BBS [43]. It should be further noted that there was a
Extension (normalised) torque
Figure 4. NP = non-paretic; P = paretic; Ext = extension torque;
90 and 80 refer to the testing joint position as percentage of
available knee joint range of motion. 90 is a relatively more
extended (straight) joint angle. Torque values are normalised to
the body weight. Error bars are group standard deviations.
Flexion (normalised) torque
Figure 5. NP = non-paretic; P = paretic; FLEX = flexion torque;
90 and 80 refer to the testing joint position as percentage of
available knee joint range of motion. 90 is a relatively more ex-
tended (straight) joint angle. Torque values are normalised to
the body weight. Error bars are group standard deviations.
ceiling effect, for this measure for 2 participants at fol-
low-up. As a consequence it was possible that the results
did not fully demonstrate the improvement achieved.
The 10 m walk test also indicated an improvement.
Nine of the eleven tested improved their walking speed
post intervention and there was a general trend for im-
provement from baseline to the follow-up testing ses-
sions. However, these changes did not reach significance
level. The improvement from baseline to post-training
session was significant (p = 0.03) on a 1-tail sign test.
These pairwise results supported an overall trend towards
improvement. MDC for chronic stroke is documented as
a 16% change [44] and the baseline to follow up changes
achieved this illustrating a 37% improvement in walking
speed. The minimally clinically important difference
(MCID) is reported in the subacute population as 0.16
m/s [45]. This study indicated a MCID change of 0.15
m/s in this chronic population.
3.3. Measure of Participation
The SIPSO scores indicated a borderline significant
Copyright © 2013 SciRes. OPEN ACCESS
C. Kilbride et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 40-51
Copyright © 2013 SciRes. OPEN ACCESS
Table 3. Mean (SD) of outcome measures at baseline (T0), post intervention (T1), and 3 months follow-up (T2).
T0 T1 T2 Sig.
BBS2 44.09 (11.90) 49.36 (11.13) 50.25 (8.78) F(2,11) = 10.63; p < 0.0022
10 m walk 25.08 (24.15) 18.85 (16.67) 18.06 (13.55) F(2,11) = 1.69 ns
SIPSO total1 23.32 (6.45) 26.84 (6.81) 28.83 (6.10) χ2(2) = 6.26; p = 0.0441
SIPSO section a (physical)2 11.84 (4.72) 13.84 (4.23) 14.17 (4.86) F(2,22) = 1.72 ns
SIPSO section b (social)2 11.47 (3.41) 13 (3.96) 13.75 (3.02) F(2,22) = 1.78 ns
Note. BBS—increase score indicate improvement, 10 m walk—decrease score indicates improvement, SIPSO—increase score indicates improvement.
1Analysed with Friedman’s two way analysis of variance. 2Analysed with ANOVA.
improvement overall (p = 0.044). However, when con-
sidered independently, the changes in physical and social
subsections were non-significant (Physical: F[2,22] = 1.72,
ns; Social: F[2,22] = 1.78, ns).
The purpose of the study was to evaluate the effec-
tiveness of a twelve-week ARNI functional training pro-
gramme delivered in a group format on measures of im-
pairment, activity, and participation in stroke survivors.
While no significant improvement in the strength of the
lower limb and COP-based measures of postural steadi-
ness were noted, an improvement in functional balance
activity and a trend toward walking faster post interven-
tion were seen. The SIPSO showed a significant overall
improvement in the level of participation, but the physi-
cal and social subsections did not alter significantly.
4.1. Effect of ARNI Functional Training on
4.1.1. Knee Extensor Muscles Group
In contrast to the results of the present study, im-
provement in muscle strength with functional training in
stroke patients has been reported before [46-48]. How-
ever, in these studies examination of the isometric mus-
cle strength was mostly conducted at angles which fa-
voured torque production, i.e. at longer lengths of the
muscle. In the present study the extensor muscles group
were tested at short lengths at angles similar to those
adopted during the stance phase of gait [49,50]. Inas-
much as extension torque was not tested at long muscle
lengths, it was not possible to rule out if improvement in
muscle strength had occurred at long lengths. Selective
weakness of the hemiparetic muscles at shorter muscles
lengths have been reported elsewhere in the literature,
with this impairment attributed to the reduced rate of
motor unit firing, differentially reduced excitability of
the motor cortex, and changes in the operating range of
the extensor muscles amongst others [51-54]. Present
findings support the relative weakness of the knee ex-
tensor muscles group in the P compared to the NP side,
and suggest that the employed functional training regime
did not affect the underlying impaired mechanisms for
the selective muscle weakness at shorter lengths in
twelve weeks.
Lack of improvement in muscle strength with training
in the present study could also be an artefact due to the
methodology employed for the analysis of the dyna-
mometry results. As stated before, some participants
were not capable of producing torque above the values
used by the dynamometry system for gravity correction
at the initial assessment, but they produced recordable
torque in the subsequent sessions (Figure 6). For these
participants, we perhaps overestimated the maximal
torque by using the individualised gravity correction
value in the pre-testing session for the analysis. There-
fore increase in muscle strength after intervention, rep-
resented by small recordable torque, might have not
reached to the level of significance.
4.1.2. Knee Flexor Muscles Group
For the flexor group, the present results are partially
consistent with those of Koo et al. [54] who employed a
range of different joint angles to evaluate the strength of
the elbow flexor muscles in a group of hemiparetic and
control participants. Koo et al. [54] found no difference
in the flexion torque between the two groups, but re-
ported that at the shorter lengths of the muscle, i.e. at the
more flexed positions, flexor muscles in the hemiparetic
group were relatively weaker. In the current study,
strength in the Hamstrings group was only assessed at
the longer lengths. Therefore, the results are not against
the notion of joint position dependency of muscular
weakness in stroke survivors as discussed by Koo et al.
and others (indicated above), but do not fully support the
similarity of the knee flexion strength between the P and
NP since a significant difference between the P and NP
flexion torque was observed when the results of the pre-
and post-testing sessions were compared.
4.1.3. Relationship between Impairment and
Existence of a correlation between strength and activ-
C. Kilbride et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 40-51
0 1000 2000 3000 4000 5000
Torque (Nm)
Time (msec)
Ext - T2
Ext - T3
Flex - T2
Flex - T3
Ext - T2
Ext - T3
Flex - T2
Flex - T3
Ext - T2
Ext - T3
Flex - T2
Flex - T3
0 1000 2000 3000 4000 5000
Time (msec)
0 1000 2000 3000 4000 5000
Time (msec)
Torque (Nm)
Torque (Nm)
Figure 6. Extension and flexion torques produced by a participant at the 90% of the
available range of motion in the pre- (upper panel) and post-training (middle panel), and
follow-up (lower panel) sessions. Ext = extension torque; Flex = flexion torque; T2 and
T3 refer to the second and third attempt from which maximum torques were calculated.
Choice of sign for torques is arbitrary. The participant was incapable of producing exten-
sion torque at the tested angle in both pre- and post-training sessions (hence the over-
lapped flat lines), but produced recordable torques in the follow-up session during the
third attempt.
ity (function) after stroke is a matter of controversy [11,
55,56]. In the present study, a significant improvement in
the BBS and a trend toward improvement in walking
speed demonstrated partial improvement in the activity
level which was not associated with improvement in
strength. Klein et al. [12] also reported that the preferred
gait speed was not limited by the weakness in stroke pa-
tients. There are some explanations for the apparent lack
of association between measures of function and strength.
It has been suggested that measures of strength similar to
that employed in the present study are context specific
and whether a measure of static strength (e.g. maximum
isometric torque) can be representative of strength during
dynamic tasks (such as walking) is not clear [57]. Other
measures of strength (e.g. isokinetic peak torque and
work of the knee extensor muscles) were significantly
correlated to the gait velocity (particularly at faster
speeds) in chronic stroke survivors [72,73]. Differences
in the methodology (with isokinetic assessment of
strength resembling more to the strength requirement
during dynamic tasks), and recruitment of a group of
more homogenous and less impaired participants in these
studies might explain differences in the findings.
Studies which reported a significant correlation be-
tween the maximum isometric strength of the knee ex-
tensor and flexor muscles and walking speed and endur-
ance in stroke population only reported low to medium
values for the relationship between the two variables
Copyright © 2013 SciRes. OPEN ACCESS
C. Kilbride et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 40-51 47
[58-60]. It has also been argued that motor behaviour of
patient populations follows a non-linear trend where for
some individuals, small (insignificant) alteration in one
measure (e.g. strength) might result in a significant
change in the behaviour (e.g. ability to stand or walk
faster), whilst for others, it only prevents deterioration of
the current condition [61]. This is similar to the sugges-
tion made by Bohannon [62] who argued that a strength
threshold related to the functional demand of a task
should be reached for the successful completion of the
task, beyond which increase in strength would not have
any significant further influence on the efficiency of the
task performance. In such circumstances improvement of
strength might improve the speed of the task completion
or act as a reserve against deterioration of the perform-
4.1.4. Relationship between Clinical and
Biomechanical Measures of Balance
The significant improvement in balance as demon-
strated by the BBS was in line with improvement re-
ported in similar studies of exercise groups after stroke
[63,64]. Of particular interest, however, was the im-
provement across all participants irrespective of their age
and time post stroke. Such improvement was not associ-
ated with alteration in the COP-based measures of pos-
tural stability, or increased strength in the P leg [74].
Participants were included in the present study if they
could maintain an unsupported stance for two minutes,
and hence would score maximum points in the “standing
unsupported” item of the BBS. Therefore, any changes in
the other aspects of balance abilities assessed by the BBS
could result in a lack of association between the results
of the two tests. Only moderate correlation between the
BBS and COP-based measures of balance has been re-
ported before and authors attributed the findings to the
different aspects of the balance abilities represented by
these tests [65,66]. ARNI training included standing up
from the floor and transfer of weight alternatively to the
stronger and weaker sides of the body during functional
tasks. It is therefore possible that the underlying mecha-
nisms for the more dynamic balance activities benefited
further from the training.
4.2. ARNI Functional Training May Improve
Quality of Life
In view of these positive results in activity it is per-
haps surprising that the SIPSO did not indicate more
extensive changes in quality of life, although the trend
was for some improvement. Previous work has ques-
tioned the direct link between physical capacity and
quality of life [67] and the present results suggest that
this relationship is certainly not linear. The SIPSO con-
siders a variety of factors including both community
ambulation and communication with friendship networks.
Three participants had communication problems which
naturally were not addressed in the ARNI training.
Walking speed is a commonly used indicator of activity
potential and therefore can have an important difference
on the stroke survivors’ ability to interact with their sur-
roundings. However, while walking speed and balance
are associated with community walking, other factors
such as confidence and self-efficacy are equally impor-
tant and were not measured in this study [68].
It is argued that results such as those reported in this
paper reinforce the call to extend rehabilitation pathways
beyond the initial acute and sub-acute periods and ques-
tion the effectiveness of the current environment for
stroke survivors to maximise their activity and functional
potential [69]. They further highlight a need for an ex-
tended rehabilitation pathway supported by community
resources. Previous research has involved fitness in-
structors in providing exercise to stroke survivors with
some positive results [47,64]. However, research also
indicates that uptake and continuation is limited by ac-
cess to specialised gym facilities and self-consciousness
created as a result of exercising with able bodied people
[70,71]. This study was run in a health facility but re-
quired no specialist gym equipment, and while it was run
in a group format, the results would indicate that suffi-
cient training effect was achieved for at least the clinical
measures to change.
4.3. Limitations
A sample of convenience was recruited for this eva-
luative study and there were no control participants. The
participating group was comprised of a broad range of
stroke survivors with different levels of motor impair-
ment who received training in a group format which rep-
resented a real life situation. The standard model of the
ARNI programme is on a 1:1 basis with resultant finan-
cial implications. The present study only supports the
effectiveness of the ARNI training in a group format as a
form of service delivery for stroke survivors, where spe-
cific trainings are individualised according to the abilities
of the trainee [75].
Instructors who delivered the training were blinded to
recruitment and hence the participants in the present
study were not treated differently from the remaining of
the training group. The research group was independent
from ARNI.
In summary, twelve weeks of ARNI functional train-
ing positively affected activity and participation levels in
a group of stroke survivors. Such improvements were
however not associated with improvement at an impair-
Copyright © 2013 SciRes. OPEN ACCESS
C. Kilbride et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 40-51
ment level. No adverse effect was observed as a result of
participating in the training or assessment sessions, and
hence, the training can be undertaken as an adjunct to
rehabilitation plans or as part of a longer term personal
plan for health and wellbeing.
Authors would like to thank London Borough of Hillingdon for fi-
nancial support, Jackie O’Dowd for recruitment of the participants of
this project.
[1] National Audit Office (2010) Progress in improving stroke
care: A good practice guide. National Audit Office.
[2] Townsend, N., Wickramasinghe, K., Bhatnagar, P., Smolina,
K., Nichols, M., Leal, J., Luengo-Fernandez, R. and Rayner,
M (2012). Coronary heart disease statistics. British Heart
Foundation, London.
[3] Wolfe, C.D. (2000) The impact of stroke. British Medical
Bulletin, 56, 275-286.
[4] Saka, O., McGuire, A. and Wolfe, C. (2009) Cost of
stroke in the United Kingdom. Age Ageing, 38, 27-32.
[5] Hackett, M.L., Yapa, C., Parag, V. and Anderson, C.S.
(2005) Frequency of depression after stroke: A systematic
review of observational studies. Stroke, 36, 1330-1340.
[6] Sandercock, P., Dennis, M., Warlow, C., Van Gijn, J.,
Hankey, G., Bamford, J. and Warlow, J. (2001) Stroke: A
practical guide to management. Wiley, Hoboken.
[7] Ada, L., Dorsch, S. and Canning, C.G. (2006) Strength-
ening interventions increase strength and improve activity
after stroke: A systematic review: 1. The Australian Jour-
nal of Physiotherapy, 52, 241-248.
[8] Patten, C., Lexell, J. and Brown, H.E. (2004) Weakness
and strength training in persons with poststroke hemiple-
gia: Rationale, method, and efficacy. Journal of Reha-
bilitation Research and Development, 41, 293-312.
[9] Prado-Medeiros, C.L., Silva, M.P., Lessi, G.C., Alves,
M.Z., Tannus, A., Lindquist, A.R. and Salvini, T.F. (2012)
Muscle atrophy and functional deficits of knee extensors
and flexors in people with chronic stroke. Physical Ther-
apy, 92, 429-439. http://dx.doi.org/10.2522/ptj.20090127
[10] Hafer-Macko, C.E., Ryan, A.S., Ivey, F.M. and Macko,
R.F. (2008) Skeletal muscle changes after hemiparetic
stroke and potential beneficial effects of exercise inter-
vention strategies. Journal of Rehabilitation Research
and Development, 45, 261.
[11] Horstman, A.M., Beltman, M.J., Gerrits, K.H., Koppe, P.,
Janssen, T.W., Elich, P. and de Haan, A. (2008) Intrinsic
muscle strength and voluntary activation of both lower
limbs and functional performance after stroke. Clinical
Physiology and Functional Imaging, 28, 251-261.
[12] Klein, C.S., Brooks, D., Richardson, D., McIlroy, W.E.
and Bayley, M.T. (2010) Voluntary activation failure
contributes more to plantar flexor weakness than antago-
nist coactivation and muscle atrophy in chronic stroke
survivors. Journal of Applied Physiology, 109, 1337-
1346. http://dx.doi.org/10.1152/japplphysiol.00804.2009
[13] Miller, M., Flansbjer, U. and Lexell, J. (2009) Voluntary
activation of the knee extensors in chronic poststroke sub-
jects. American Journal of Physical Medicine & Reha-
bilitation, 88, 286-291.
[14] Bleyenheuft, Y. and Thonnard, J.L. (2011) Tactile spatial
resolution in unilateral brain lesions and its correlation
with digital dexterity. Journal of Rehabilitation Medicine,
43, 251-256. http://dx.doi.org/10.2340/16501977-0651
[15] Kiyama, R., Fukudome, K., Hiyoshi, T., Umemoto, A.,
Yoshimoto, Y. and Maeda, T. (2011) The loss of dexter-
ity in the bilateral lower extremities in patients with
stroke. Journal of Applied Biomechanics, 27, 122-129.
[16] Lubetzky-Vilnai, A. and Kartin, D. (2010) The effect of
balance training on balance performance in individuals
poststroke: A systematic review. Journal of Neurological
Physical Therapy, 34, 127-137.
[17] Marigold, D.S. and Eng, J.J. (2006) Altered timing of
postural reflexes contributes to falling in persons with
chronic stroke. Experimental Brain Research, 171, 459-
468. http://dx.doi.org/10.1007/s00221-005-0293-6
[18] Esquenazi, A., Ofluoglu, D., Hirai, B. and Kim, S. (2009)
The effect of an ankle-foot orthosis on temporal spatial
parameters and asymmetry of gait in hemiparetic patients.
PM & R, 1, 1014-1018.
[19] Patterson, K.K., Parafianowicz, I., Danells, C.J., Closson,
V., Verrier, M.C., Staines, W.R., Black, S.E. and McIlroy,
W.E. (2008) Gait asymmetry in community-ambulating
stroke survivors. Archives of Physical Medicine and Re-
habilitation, 89, 304-310.
[20] Department of Health (2007) National stroke strategy.
Department of Health, London.
[21] The Stroke Association (2010) Moving on: A vision for
community based physiotherapy after stroke in England.
[22] Verheyden, G. and Ashburn, A. (2011) Stroke. In: Stokes,
M. and Stack, E., Eds., Physical Management for Neuro-
logical Conditions, 3rd Edition, Elsevier Churchill Liv-
ingstone, London, 9-28.
[23] Hendricks, H.T., van Limbeek, J., Geurts, A.C. and
Zwarts, M.J. (2002) Motor recovery after stroke: A sys-
tematic review of the literature. Archives of Physical
Medicine and Rehabilitation, 83, 1629-1637.
[24] Demain, S., Wiles, R., Roberts, L. and McPherson, K.
(2006) Recovery plateau following stroke: Fact or fiction?
Disability and Rehabilitation, 28, 815-821.
Copyright © 2013 SciRes. OPEN ACCESS
C. Kilbride et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 40-51 49
[25] The Stroke Association (2012) Struggling to recover. The
Stroke Association, London.
[26] Winchcombe, M. (2012) A life more ordinary—Findings
from the long-term neurological conditions research ini-
[27] Horgan, J., Bethell, H., Carson, P., Davidson, C., Julian,
D., Mayou, R.A. and Nagle, R. (1992) Working party re-
port on cardiac rehabilitation. British Heart Journal, 67,
412-418. http://dx.doi.org/10.1136/hrt.67.5.412
[28] Morgan, O. (2005) Approaches to increase physical activ-
ity: Reviewing the evidence for exercise-referral schemes.
Public Health, 119, 361-370.
[29] Sharma, H., Bulley, C. and van Wijck, F.M.J. (2011)
Experiences of an exercise referral scheme from the per-
spective of people with chronic stroke: A qualitative
study. Physiotherapy, 98, 336-343.
[30] Bethell, H., Lewin, R. and Dalal, H. (2009) Cardiac reha-
bilition in the United Kingdom. Heart, 95, 271-275.
[31] Brazzelli, M., Saunders, D.H., Greig, C.A. and Mead,
G.E. (2012) Physical fitness training for patients with
stroke: Updated review. Stroke, 43, e39-e40.
[32] Intercollegiate Stroke Working Party (2012) Maintaining
standards—The national clinical guideline for stroke. 4th
Edition, London.
[33] Balchin, T. (2011) The successful stroke survivor. Bag-
wyn, Surrey.
[34] Luton stroke service on the world stage (2012).
[35] Stroke survivors information page.
[36] Trigg, R. and Wood, V.A. (2000) The subjective index of
physical and social outcome [SIPSO]: A new measure for
use with stroke patients. Clinical Rehabilitation, 14, 288-
299. http://dx.doi.org/10.1191/026921500678119607
[37] Prieto, T.E., Myklebust, J.B., Hoffmann, R.G., Lovett,
E.G. and Myklebust, B.M. (1996) Measures of postural
steadiness: Differences between healthy young and eld-
erly adults. IEEE Transactions on Biomedical Engineer-
ing, 43, 956-966. http://dx.doi.org/10.1109/10.532130
[38] Bohannon, R.W. and Andrews, A.W. (1998) Relation-
ships between impairments in strength of limb muscle ac-
tions following stroke. Perceptual Motor Skills, 87, 1327-
1330. http://dx.doi.org/10.2466/pms.1998.87.3f.1327
[39] Bohannon, R.W. (2008) Is it legitimate to characterize
muscle strength using a limited number of measures?
Journal of Strength and Conditioning Research, 22, 166-
173. http://dx.doi.org/10.1519/JSC.0b013e31815f993d
[40] Jaric, S. (2002) Muscle strength testing: Use of normali-
sation for body size. Sports Medicine, 32, 615-631.
[41] Jaric, S., Radosavljevic-Jaric, S. and Johansson, H. (2002)
Muscle force and muscle torque in humans require dif-
ferent methods when adjusting for differences in body
size. European Journal of Applied Physiology, 87, 304-
307. http://dx.doi.org/10.1007/s00421-002-0638-9
[42] Berg, K.O., Wood-Dauphinee, S.L., Williams, J.T. and
Gayton, D. (1989) Measuring balance in the elderly: Pre-
liminary development of an instrument. Physiotherapy
Canada, 41, 304-311.
[43] Liston, R.A. and Brouwer, B.J. (1996) Reliability and
validity of measures obtained from stroke patients using
the balance master. Archives of Physical Medicine and
Rehabilitation, 77, 425-430.
[44] Flansbjer, U., Holmbäck, A.M., Downham, D., Lexell, J.
and Sektion, I.V. (2005) What change in isokinetic knee
muscle strength can be detected in men and women with
hemiparesis after stroke? Clinical Rehabilitation, 19, 514-
522. http://dx.doi.org/10.1191/0269215505cr854oa
[45] Tilson, J., Sullivan, K., Cen, S., et al. (2010) Meaningful
gait speed improvement during the first 60 days post
stroke: Minimal clinically important difference. Physical
Therapy, 90, 196-208.
[46] Bale, M. and Strand, L.I. (2008) Does functional strength
training of the leg in subacute stroke improve physical
performance? A pilot randomized controlled trial. Clini-
cal Rehabilitation, 22, 911-921.
[47] Cramp, M.C., Greenwood, R.J., Gill, M., Lehmann, A.,
Rothwell, J.C. and Scott, O.M. (2010) Effectiveness of a
community-based low intensity exercise programme for
ambulatory stroke survivors. Disability and Rehabilita-
tion, 32, 239-247.
[48] Yang, Y.R., Wang, R.Y., Lin, K.H., Chu, M.Y. and Chan,
R.C. (2006) Task-oriented progressive resistance strength
training improves muscle strength and functional per-
formance in individuals with stroke. Clinical Rehabilita-
tion, 20, 860-870.
[49] Chen, C., Chen, H., Tang, S.F., Wu, C., Cheng, P. and
Hong, W. (2003) Gait performance with compensatory
adaptations in stroke patients with different degrees of
motor recovery. American Journal of Physical Medicine
& Rehabilitation, 82, 925-935.
[50] Milovanović, I. and Popović, D.B. (2012) Principal com-
ponent analysis of gait kinematics data in acute and chro-
nic stroke patients. Computational and Mathematical Me-
thods in Medicine, 2012, Article ID: 649743.
[51] Ada, L., Canning, C. and Dwyer, T. (2000) Effect of mu-
scle length on strength and dexterity after stroke. Clinical
Rehabilitation, 14, 55-61.
[52] Ada, L., Canning, C.G. and Low, S.L. (2003) Stroke pa-
tients have selective muscle weakness in shortened range.
Brain, 126, 724-731.
Copyright © 2013 SciRes. OPEN ACCESS
C. Kilbride et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 40-51
[53] Horstman, A., Gerrits, K., Beltman, M., Janssen, T., Ko-
nijnenbelt, M. and de Haan, A. (2009) Muscle function of
knee extensors and flexors after stroke is selectively im-
paired at shorter muscle lengths. Journal of Rehabilita-
tion Medicine, 41, 317-321.
[54] Koo, T.K., Mak, A.F., Hung, L.K. and Dewald, J.P.
(2003) Joint position dependence of weakness during
maximum isometric voluntary contractions in subjects
with hemi-paresis. Archives of Physical Medicine and
Rehabilitation, 84, 1380-1386.
[55] Gerrits, K.H., Beltman, M.J., Koppe, P.A., Konijnenbelt,
H., Elich, P.D., de Haan, A. and Janssen, T.W. (2009) I-
sometric muscle function of knee extensors and the rela-
tion with functional performance in patients with stroke.
Archives of Physical Medicine and Rehabilitation, 90,
480-487. http://dx.doi.org/10.1016/j.apmr.2008.09.562
[56] Ng, S. (2010) Balance ability, not muscle strength and
exercise endurance, determines the performance of hemi-
paretic subjects on the timed-sit-to-stand test. American
Journal of Physical Medicine & Rehabilitation, 89, 497-
504. http://dx.doi.org/10.1097/PHM.0b013e3181d3e90a
[57] Fleishman, E.A. (1964) What do physical fitness test
measure? A review of previous research. In: Cliffs, N.J.,
Ed., The structure and measurement of physical fitness,
Prentice-Hall, Inc., Englewood, 27-37.
[58] Dorsch, S., Ada, L., Canning, C.G., Al-Zharani, M. and
Dean, C. (2012) The strength of the ankle dorsiflexors
has a significant contribution to walking speed in people
who can walk independently after stroke: An observa-
tional study. Archives of Physical Medicine and Rehab-
ilitation, 93, 1072-1076.
[59] Pang, M. and Eng, J. (2008) Determinants of improve-
ment in walking capacity among individuals with chronic
stroke following a multi-dimensional exercise program.
Journal of Rehabilitation Medicine, 40, 284-290.
[60] Severinsen, K., Jakobsen, J.K., Overgaard, K. and An-
dersen, H. (2011) Normalized muscle strength, aerobic
capacity, and walking performance in chronic stroke: A
population-based study on the potential for endurance and
resistance training. Archives of Physical Medicine and
Rehabilitation, 92, 1663-1668.
[61] Buchner, D.M., Beresford, S.A., Larson, E.B., LaCroix,
A.Z. and Wagner, E.H. (1992) Effects of physical activity
on health status in older adults. II. Intervention studies.
Annual Review of Public Health, 13, 469-488.
[62] Bohannon, R.W. (2007) Muscle strength and muscle
training after stroke. Journal of Rehabilitation Medicine,
39, 14-20. http://dx.doi.org/10.2340/16501977-0018
[63] Cramp, M.C., Greenwood, R.J., Gill, M., Lehmann, A.,
Rothwell, J.C. and Scott, O.M. (2010) Effectiveness of a
community-based low intensity exercise programme for
ambulatory stroke survivors. Disability and Rehabilita-
tion, 32, 239-247.
[64] Stuart, M., Benvenuti, F., Macko, R., Taviani, A.,
Segenni, L., Mayer, F., Sorkin, J.D., Stanhope, S.J.,
Macellari, V. and Weinrich, M. (2009) Community-based
adaptive physical activity program for chronic stroke:
Feasibility, safety, and efficacy of the Empoli model.
Neurorehabilitation Neural Repair, 23, 726-734.
[65] Frykberg, G.E., Lindmark, B., Lanshammar, H. and Borg,
J. (2007) Correlation between clinical assessment and
force plate measurement of postural control after stroke.
Journal of Rehabilitation Medicine, 39, 448-453.
[66] Niam, S., Cheung, W., Sullivan, P.E., Kent, S. and Gu, X.
(1999) Balance and physical impairments after stroke.
Archives of Physical Medicine and Rehabilitation, 80,
[67] Hill, T., Gjellesvik, T., Moen, P., Tørhaug, T., Fimland,
M., Helgerud, J. and Hoff, J. (2012) Maximal strength
training enhances strength and functional performance in
chronic stroke survivors. American Journal of Physical
Medicine & Rehabilitation, 91, 393-400.
[68] Schmid, A.A., Van Puymbroeck, M., Altenburger, P.A.,
Dierks, T.A., Miller, K.K., Damush, T.M. and Williams
L.S. (2012) Balance and balance self-efficacy are associ-
ated with activity and participation after stroke: A cross-
sectional study in people with chronic stroke. Archives of
Physical Medicine and Rehabilitation, 93, 1101-1107.
[69] Mead, G. and Bernhardt, J. (2011) Physical fitness train-
ing after stroke, time to implement what we know: More
research is needed. International Journal of Stroke, 6,
506-508. htt p :/ /dx . do i .o r g/10 .1111/j .17 47-4 9 49 .20 11 .00679.x
[70] Rimmer, J.H., Wang, E. and Smith, D. (2008) Barriers
associated with exercise and community access for indi-
viduals with stroke. Journal of Rehabilitation Research
and Development, 45, 315-322.
[71] Scianni, A., Teixeira-Salmela, L.F. and Ada, L. (2012)
Challenges in recruitment, attendance and adherence of
acute stroke survivors to a randomized trial in Brazil: A
feasibility study. Revista Brasileira de Fisioterapia, 16,
[72] Suzuki, K., Nakamura, R., Yamada, Y. and Handa, T.
(1990) Determinants of maximum walking speed in he-
miparetic stroke patients. The Tohoku Journal of Experi-
mental Medicine, 162, 337-344.
[73] Hsu, A., Tang, P. and Jan, M. (2003) Analysis of im-
pairments influencing gait velocity and asymmetry of
hemiplegic patients after mild to moderate stroke. Ar-
chives of Physical Medicine and Rehabilitation, 84, 1185-
1193. http://dx.doi.org/10.1016/S0003-9993(03)00030-3
[74] Genthon, N., Rougier, P., Gissot, A.S., Froger, J., Pelis-
sier, J. and Perennou, D. (2008) Contribution of each
lower limb to upright standing in stroke patients. Stroke,
39, 1793-1799.
Copyright © 2013 SciRes. OPEN ACCESS
C. Kilbride et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 40-51
Copyright © 2013 SciRes. OPEN ACCESS
[75] Roland, M. and Torgerson, D.J. (1998) Understanding
Controlled Trials: What are pragmatic trials? British Medical
Journal, 316, 285.