title: Interventions for improving community ambulation in individuals with stroke.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Physical Therapy, College of Rehabilitation Science, University of Manitoba, R106-771 McDermot Avenue, Winnipeg, MB, Canada, R3E 0T6.
authors.forename: Ruth E
authors.initials: RE
authors.lastname: Barclay
authors.forename: Ted J
authors.initials: TJ
authors.lastname: Stevenson
authors.forename: William
authors.initials: W
authors.lastname: Poluha
authors.forename: Jacquie
authors.initials: J
authors.lastname: Ripat
authors.forename: Cristabel
authors.initials: C
authors.lastname: Nett
authors.forename: Cynthia S
authors.initials: CS
authors.lastname: Srikesavan
mesh_terms: D000203:Activities of Daily Living; D000328:Adult; D004779:Environment Design; D005684:Gait / Q000502:physiology; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D012111:Residence Characteristics; D020377:Self Efficacy; D000071939:Stroke Rehabilitation; D013997:Time Factors; D016138:Walking / Q000502:physiology*