815220

research-article2018
CRE0010.1177/0269215518815220Clinical RehabilitationPontes et al.

CLINICAL
Original Article REHABILITATION

Clinical Rehabilitation

Effects of isokinetic muscle 1­–14

© The Author(s) 2018
Article reuse guidelines:
strengthening on muscle strength, sagepub.com/journals-permissions
DOI: 10.1177/0269215518815220
https://doi.org/10.1177/0269215518815220

mobility, and gait in post-stroke journals.sagepub.com/home/cre

patients: a systematic review and

meta-analysis

Sarah Souza Pontes1,2,

Ana Louise Reis de Carvalho1,2,
Katna de Oliveira Almeida1,2, Murilo Pires Neves1,3,
Ingara Fernanda Silva Ribeiro Schindler1,3,4,
Iura Gonzalez Nogueira Alves1,2,
Fabio Luciano Arcanjo2,3,4
and Mansueto Gomes-Neto1,2,4

Abstract
Objective: To investigate whether isokinetic muscle strengthening improves muscle strength, mobility,
and gait in post-stroke patients.
Methods: We searched for randomized controlled trials at PubMed/Medline, SciELO, PEDro, and
Cochrane Central Register of Controlled Trials, from the earliest date available to June 2018. Randomized
controlled trials that examined the effects of isokinetic muscle strengthening versus other rehabilitation
interventions or control in post-stroke patients were included. Study quality was evaluated using the
PEDro scale. Weighted mean difference (WMD) and 95% confidence intervals (CIs) were calculated, and
heterogeneity was assessed using the I2 test.
Results: In total, 13 studies (347 patients) focusing on the use of isokinetic in rehabilitation following
stroke were included. All trials were of low-to-moderate quality. Isokinetic muscle strengthening improved
muscle strength WMD 0.8 (95% CI: 0.2, 1.4; N = 96), mobility WMD −2.03 seconds (95% CI: −2.9, −1.1;
N = 111) and gait speed WMD 0.9 m/s (95% CI: 0.05, 1.8; N = 87).
Conclusion: Isokinetic muscle strengthening seems to be a useful strategy for improving muscle strength,
mobility, and gait in post-stroke patients.

1Departamento de Fisioterapia, Instituto de Ciências da Saúde, Corresponding author:

Curso de Fisioterapia, Universidade Federal da Bahia (UFBA),
Salvador, Brazil
2Physiotherapy Research Group, Universidade Federal da
Bahia (UFBA), Salvador, Brazil
3AF Fisioterapia, Salvador, Brazil
4Programa de Pós Graduação em Medicina e Saúde,
Universidade Federal da Bahia (UFBA), Salvador, Brazil
Professor Mansueto Gomes-Neto, Departamento de
Fisioterapia, Instituto de Ciências da Saúde, Curso de
Fisioterapia, Universidade Federal da Bahia (UFBA), Av. Reitor
Miguel Calmon, s/n—Vale do Canela, 40110-100 Salvador,
Bahia, Brazil.
Email: mansueto.neto@ufba.br
2 Clinical Rehabilitation 00(0)
Keywords
Mobility, muscle strengthening, rehabilitation, stroke
Date received: 17 July 2018; accepted: 2 November 2018
Background
Post-stroke muscular dysfunction is likely a multi-
factorial phenomenon that includes contributions
from decreased descending drive and disuse that
lead to muscle atrophy and weakness.1 Loss of
muscle mass after stroke has implications for
strength and functional ability.2 Studies with post-
stroke patients have shown the potential for a
resistance training to improve not only muscle
power generation but also strength and gait speed.1,3
The isokinetic dynamometer is considered the
“gold standard” in the evaluation of muscle
strength; however, the isokinetic dynamometer is
rarely used as a rehabilitation technique in cerebral
injury patients.3 Isokinetic muscle strengthening
has been applied to many musculoskeletal condi-
tions because of the development of a maximal
moment of force over the whole range of amplitude
of movement. The use of the isokinetic dynamom-
eter may be of interest due to the reproducibility of
the exercises, and accuracy in scheduling and
building contents of work sessions. Visual and/or
auditory feedback provided by the machine in real
time, and easy monitoring of participants perfor-
mance, can increase adherence to the rehabilitation
program.4 Thus, isokinetic muscle strengthening
represents a potentially interesting technique of
rehabilitation for post-stroke patients.
Hammami et al.4 recently published a system-
atic review evaluating the effects of isokinetic
muscle strengthening after acquired cerebral dam-
age and reported the interest of isokinetic muscle
strengthening in the rehabilitation of post-stroke
patients, particularly in the lower limb. However,
they included non-experimental and/or quasi
experimental studies, which due to the presence of
information bias and selection bias can overesti-
mate the results.
Since the previous review was published, which
includes six studies, new randomized controlled
trials (RCTs) have been released, and there is no
published meta-analysis, this systematic review
and meta-analysis aimed to analyze the published
RCTs that investigated the effects of isokinetic
muscle strengthening on the muscle strength,
mobility, and gait in post-stroke patients.
Methods
This systematic review was written in accordance
with the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines.5
We searched for references on Medline,
Cochrane Central Register of Controlled Trials
(CENTRAL), Physiotherapy Evidence Database
(PEDro), and Scientific Electronic Library Online
(SciELO) up to June 2018, without language
restrictions. A standard protocol for this search was
developed, and whenever possible, controlled
vocabulary (MeSH terms for Medline/PubMed and
Cochrane) was used. Keywords and their syno-
nyms were used to sensitize the search.
This systematic review included all RCTs that
studied the effects of isokinetic muscle strengthen-
ing in the rehabilitation of post-stroke patients.
Studies were considered for inclusion regardless of
their publication status, language, or size. To be eli-
gible, each trial should have randomized post-
stroke patients (independent of time since stroke,
that is, acute, sub-acute, or chronic stages) to at
least one group of isokinetic muscle strengthening.
The main outcomes of interest were muscle
strength, gait, balance, mobility, and quality of life.
Isokinetic muscle strengthening was defined
as the use of isokinetic dynamometer how a reha-
bilitation technique for muscle strengthening. We
included all RCTs that studied the effects of
isokinetic muscle strengthening compared to
other exercise interventions or control (no exer-
cise training).
The optimally sensitive search strategy developed
by Higgins and Green6 was used to identify
RCTs in PubMed/Medline. There were three groups
Pontes et al. 3
of keywords: study design, participants, and inter-
ventions. The full search strategy can be found in
Electronic Supplementary File 1 for independent
replication.
We checked the references of the articles
included in this systematic review to identify other
potentially eligible studies. For ongoing studies or
when the confirmation of any data or additional
information was needed, the authors were con-
tacted by email.
The search strategy was used to obtain the titles
and abstracts of studies that might be relevant for
this review. Each abstract identified in the research
was independently evaluated by two authors (S.S.P.
and A.L.R.d.C.). If at least one of the authors con-
sidered one reference as eligible, the full text was
obtained for complete assessment. Two reviewers
independently (S.S.P. and A.L.R.d.C.) evaluated
the full-text articles for eligibility using inclusion
and exclusion criteria. In the event of any disagree-
ment, each of the authors discussed the reasons for
their decisions, and a final decision was made by
consensus.
Two authors independently (S.S.P. and
A.L.R.d.C.) extracted data from the published
reports using standard data extraction forms
adapted from The Cochrane Collaboration’s4 model.
The aspects of the study population, types of inter-
vention performed, follow-up and loss to follow-
up, outcome measures, and results were reviewed.
Disagreements were resolved by one of the authors.
Any further information required from the original
author was requested by email.
The quality of studies included in this system-
atic review was scored by two researchers using
the PEDro scale, which is based on the important
criteria, such as the concealed allocation, intention-
to-treat analysis, and adequacy of follow-up. These
characteristics make the PEDro scale a useful tool
for assessing the quality of rehabilitation trials.7–9
Most trials had already been rated at least twice by
trained evaluators of PEDro database (http://www
.pedro.fhs.usyd.edu.au/). If a trial was not included
in PEDro or had not been previously rated twice, it
was rated independently by our two researchers.
Any disagreements in the rating of the studies were
resolved by a third reviewer (M.G.-N.)
The certainty of evidence and the strength of rec-
ommendations for the outcomes muscle strength,
mobility, and gait after isokinetic muscle strength-
ening of our meta-analysis were assessed using
the Grading of Recommendations, Assessment,
Development and Evaluation (GRADE) system’s
GRADEpro software, the results of which are pre-
sented in the Summary of Findings6 (Electronic
Supplementary File 2).
Data synthesis and analysis
Pooled effect estimates were obtained by compar-
ing the least square mean percentage change from
the baseline to the end of the study for each group
and were expressed as the standard mean difference
between groups. When the standard deviation (SD)
of the between-group difference was not available,
the SD of the control group at baseline measure was
used for the meta-analysis. Calculations were made
using fixed and random effects models, and one
comparison was made: isokinetic muscle strength-
ening versus conventional rehabilitation group.
Standardized mean differences (SMDs) were calcu-
lated from mean values and SDs of the muscle
strength and gait speed data. The SMDs of 0.2, 0.5,
and 0.8 were considered to be small, moderate, and
large, respectively. A α value of 0.05 was consid-
ered significant. Statistical heterogeneity of the
treatment effects among studies was assessed using
Cochran’s Q-test and the inconsistency I2 test,
where values above 25% and 50% were considered
indicative of moderate and high heterogeneity,
respectively.10 All analyses were conducted using
the Review Manager version 5.3 (The Cochrane
Collaboration).11
Results
The initial search led to the identification of 599
abstracts, 19 of which were considered potentially
relevant and were retrieved for detailed analysis.
Thirteen studies met the eligibility criteria. The list
of excluded papers and reasons for exclusion can
be found in Electronic Supplementary File 3.
Figure 1 shows the PRISMA flow diagram of
studies in this review. The remaining 13 papers12–24
4 Clinical Rehabilitation 00(0)

Figure 1.  Search and selection of studies for systematic review according to PRISMA.

involving 347 patients were fully analyzed and
approved by both reviewers, and data were
extracted. Each of the papers was scored using the
PEDro scale methodology by both reviewers.
Studies included in this review had PEDro scores
of 3–7. The results of the assessment of the PEDro
scale are presented individually in Supplementary
Table 1.
The number of participants analyzed in the
included studies ranged from 1623 to 5016. The mean
age of the participants ranged from 51 to 66 years.
All of the studies included patients of both genders,
but there was an overall predominance of male
participants. One study included patients within
two weeks of stroke onset, while others included
patients with more than six months of stroke.
Table 1 summarizes the characteristics of the
included studies.
Five trials compared isokinetic muscle strength-
ening to another method of muscle reinforcement
(one trial performed isokinetic eccentric resistance
exercises for the hip flexor and extensor muscles,
one trial performed isokinetic knee concentric/
eccentric flexion/extension, one trial trained the
subjects for isokinetic muscle strengthening of the
quadriceps alone, and two trials applied concentric
Table 1.  Characteristics of included studies.

Study/setting Sample Gender Paretic side Outcomes Key findings Drop-outs,

size Age (y) Stroke time n (%)
(months)
Pontes et al.

Coroian 20 (16) M (16) L (4) Wrist and elbow muscle UL-FMS increase 3.5 (±4.4) in the IST group 4 (3.2)
et al.12/France 63.6 >6 strength versus 6.0 (± 4.5) in the control group (P = 0.2).
Upper Limb Fugl-Meyer Gains in distal UL-FMS were larger in the control
Score (UL-FMS) group 3.1 (±2.8) versus 0.6 (±2.5) in the IS group
Box and Block Test (P = 0.05). No significant group difference was
BI unveiled in secondary endpoints
Spasticity
Gharib and 30 (30) M (16)/F (14) L (17)/R (13) Knee peak torque Patients in both groups showed significant 0
Mohamed13/ 54.06 NR TUG improvement post treatment in peak torque of
Egypt Gait parameters knee and ankle muscles, gait parameters, and
TUG test (P < 0.05). Between-group comparison
revealed significant difference for peak torque of
both knee and ankle muscles, walk speed (t = 2.44,
P = 0.02), gait cycle time, and TUG in favor of the
experimental group (P < 0.05)
Singhal et al.14/ 30 (30) M (26)/F (4) NR 6MWT Isokinetic strengthening group showed significantly 0
India 51.27 4–21 hip, knee, and ankle muscle better improvement in peak torque of hip flexor,
strength hip extensor, knee flexor, knee extensor, and
Step length 6MWT
Chen et al.15/ 31 (24) M (13)/F (11) L (12)/R (12) Knee muscle strength There were more peak torques, and SF-36 7 (7.4)
Taiwan 65.95 >6 TUG items significantly improved in the isokinetic
Quality of life (SF-36) training group compared with the isotonic group
(P < 0.05)
Şen et al.16/ 50 (50) M (33)/F (17) L (18)/R (32) Knee and ankle Muscle PT change values were significantly higher in the 0
Turkey 53.35 2–9 strength isokinetic group than the control group except
FIM for the values of the knee extension at 180°/s AV,
SSQoL ankle extension at 60°/s AV on paretic side; ankle
Timed 10-Meter Walk Test extension at 60°/s AV, and flexion at 120°/s AV on
6MWT non-paretic side (all P < 0.025)
Stair-climbing Test
TUG
BBS
RMI
Stages of Brunnstrom
5

(Continued)
 6

Table 1. (Continued)

Study/setting Sample Gender Paretic side Outcomes Key findings Drop-outs,

size Age (y) Stroke time n (%)
(months)
Lee & Kang17/ 20 (20) M (13)/F (7) L (9)/R (11) Hip muscle strength Compared to the baseline, the experimental 0
Korea 53.63 >6 TUG group presented significant differences in muscle
Stair up and down time strength, stair up and down time, gait velocity, and
10-m gait velocity TUG time
Milot et al.18/ 30 (30) M (18)/F (12) L (18)/R (12) Muscle strength of upper After training, both groups showed a similar and 0
Canada 56.6 >6 limbs and lower limbs significant increase in gait speed, positive power of
Quality of life (SF-36) the hip muscles, and plantar flexors strength
BBS
Chedoke-McMaster
Semmes Weinstein filaments
Action Research Arm Test
HAP
5-Meter Walk Test
Sekhar et al.19/ 40 (40) NR NR Modified Ashworth Scale Group II had shown a statistically significant 0
India 30–50 BBS improvement at 0.05 level with the outcome
Muscle strength of the knee measures, that is, isokinetic peak torque at 30°/s
shows P = 0.018, 60°/s shows P = 0.031, 90°/s
shows P = 0.015, and BBS and its score shows
P = 0.004
Shimodozono 25 (25) M (13)/F (12) L (13)/R (12) Knee Muscle strength The changes in the isometric peak torque of the 0
et al.20/Japan 64.45 1–8 Muscle cross-sectional area knee flexor muscles at two, four, and six weeks
BI in the AAS group were significantly greater than
Stages of Brunnstrom those in the control group
Kim et al.21/ 16 (16) M (14)/F (2) L (8)/R (8) Trunk muscle strength In the experimental group, peak torques of trunk 0
Korea 52.5 >6 BBS extensor increased significantly at 60°/s and 90°/s
10-m gait velocity at four weeks (P < 0.05)
Sit to stand
TUG
Stair up and down
Seo et al.22/ 21 (21) M (18)/F (3) L (11)/R (10) Muscle strength of the knee Significantly, higher mean percent changes of 0
Korea >6 Gait speed peak torque and total work were observed in
Stair up and down time the experimental group compared to the control
Sit-to-stand time group at all eccentric angular velocities tested
Clinical Rehabilitation 00(0)
 Pontes et al.

Table 1. (Continued)
Study/setting Sample Gender Paretic side Outcomes Key findings Drop-outs,
size Age (y) Stroke time n (%)
(months)
Kim et al.23/ 20 (20) M (14)/F (6) L (9)/R (11) Quality of life (SF-36) Both the experimental and control groups 0
Canada 61.15 >6 Lower limbs muscle strength increased their strength and walking speed post-
Level-walking performance intervention; however, there were no differences
Stair-walking performance in the changes in walking speed between the
Chedoke-McMaster groups. No changes in SF-36 scores were found in
either group
Engardt 20 (20) M (15)/F (5) L (12)/R (8) Knee muscle strength The eccentric and the concentric strength 0
et al.24/Sweden 63.4 >6 Fugl-Meyer increased in the eccentrically trained group
MAS (P < 0.05). The restraint of the antagonistic
Sensibility muscles in concentric movements increased after
Electromyography concentric (P < .05), but not eccentric training.
Gait A nearly symmetrical body weight distribution
on the legs in rising from a sitting position was
noted after eccentric (P < .05), but not concentric
training

M: Male; F: female: L: Left: R: Right; IST: isokinetic strengthening training; BI: Barthel Index; FMA: Fugl-Meyer Upper Limb; NR: not reported; TUG: Timed Up and Go test;
6MWT, 6-minute walk test; FIM: Functional Independence Measure; SSQoL: Stroke Specific Quality-of-Life Scale; BBS: Berg Balance Scale; RMI: Rivermead Mobility Index;
HAP: Human Activity Profile; MAS: Motor Assessment Scale; BBT: Box and Block Test; EMG: electromyography; SWME: Semmes Weinstein monofilament; 10MWT, Timed
10-meter walk test; 5MWT: 5-meter walk test.
7
8 Clinical Rehabilitation 00(0)
isokinetic strengthening training to the knee and
ankle muscles), two trials compared isokinetic
muscle strengthening to passive mobilization, one
trial compared two methods of isokinetic muscle
strengthening (one group trained exclusively
eccentric movements and the other exclusively
concentric movements), and one trial compared the
addition of an anabolic steroid to isokinetic muscle
strengthening to isokinetic muscle strengthening
alone.
The training characteristics used in the applica-
tion of isokinetic muscle strengthening were
reported in most studies. Overall, three to six weeks
of isokinetic muscle strengthening programs were
performed. Furthermore, sessions were performed
2–5 times per week. Most isokinetic muscle
strengthening programs used the Cybex (n = 5) and
Biodex (n = 4) dynamometers or other types of
isokinetic dynamometers (n = 4) with training in the
sitting position. Most studies presented isokinetic
muscle strengthening for each limb separately. In
isokinetic protocols, proposed speeds for strength-
ening programs vary between 15°/s and 180°/s.
Both concentric and eccentric contractions were
used. A one-minute recovery interval between
series is described in all studies. The number of rep-
etitions varies, with programs of up to 15 sets not
exceeding 10 contractions in each set. In the trial by
Engardt et al.,24 two modes of isokinetic strengthen-
ing, concentric and eccentric, were compared. The
characteristics of isokinetic strengthening training
in included studies are provided in Table 2.
Effect of isokinetic strengthening training
A single trial showed that eccentric knee extensor
training may be more suitable for stroke patients
than concentric training.24 Another trial showed
that isokinetic strength training and balance exer-
cise were found to be more effective in improving
the strength of the quadriceps in the lower limb and
balance in subjects with stroke compared to the
conventional physiotherapy.19 In the trial by Şen
et al.,16 bilateral isokinetic strengthening training
in addition to the conventional rehabilitation
program after stroke was more effective than the
conventional rehabilitation for muscle strength on
both sides, gait speed, balance, and quality of life.
In the trial by Lee and Kang,17 isokinetic eccentric
resistance exercise for the hip joint flexor and
extensor muscles in addition to conventional phys-
ical therapy was more effective than conventional
physical therapy for hip muscle strength, stair up
and down time, gait speed, and mobility. However,
in the trial by Chen et al.,15 isokinetic strengthening
training with conventional rehabilitation was not
more effective than isotonic strengthening training
with conventional rehabilitation for muscle
strength, mobility, and quality of life.
Only Coroian et al.12 evaluated the effect of
isokinetic muscle strengthening on spasticity. The
authors reported that there was no significant dif-
ference in spasticity between groups.
Five studies13,15,16,17,22 assessed the knee muscle
strength as an outcome. A total of 146 patients were
included in these five studies. Due to the difference
between the instruments used in the assessment of
muscle strength, we performed a meta-analysis
with SMD. The meta-analyses Figure 2) showed
significant improvement in knee muscle extension
strength at 0.71 (95% confidence interval (CI): 0.3,
1.1; N = 146) for participants in the isokinetic
strengthening training group compared to those in
the conventional rehabilitation group.
Five studies13,15,16,17,21 assessed the mobility as
an outcome. A total of 141 patients were included
in these five studies. The meta-analyses (Figure 3)
showed significant improvement in mobility at
−3.2 seconds (95% CI: −5.5, −1.0; N = 141) for par-
ticipants in the isokinetic strengthening training
group compared to those in the conventional reha-
bilitation group.
Five studies13,16,17,21,22 assessed the gait speed as
an outcome. A total of 137 patients were included
in these five studies. Due to the difference between
the instruments used in the assessment of muscle
strength, we performed a meta-analysis with SMD.
The meta-analyses (Figure 4) showed significant
improvement in gait speed at 0.64 m/s (95% CI:
0.15, 1.1; N = 137) for participants in the isokinetic
strengthening training group compared to those in
the conventional rehabilitation group.
Table 2.  The characteristics of isokinetic strengthening training in the studies included in the systematic review.
Study Groups/isokinetic type
Coroian et al.12 GE: IST/CONTREX dynamometer
GC: Passive mobilization
Gharib and GE: IST + CR
Mohamed13 GC: CR
Singhal et al.14 GE: IST (isokinetic CSMI HUMAC/
NORM) + CR
G2 control: Functional
Strengthening + Conventional
Physiotherapy
Chen et al.15 GE IST (Biodex dynamometer)
GC Isotonic muscle strengthening
(Biodex dynamometer)
Şen et al.16 GE IST Concentric (Isokinetic
Biodex system 3 pro)
GC: CR
Lee and Kang,17 GE: Eccentric IST (Dynamometer
Cybex 770)
GC: CR
Milot et al.18 GE: IST Concentric Lower limb
(Dynamometer Cybex) LL
GC: IST Concentric Upper limb
(Dynamometer Cybex)
Repetitions, velocity Frequency Length
(× per week) (week)
Pontes et al.
10-minute warm-up (3 × 6 for elbow flexion and extension 3 6
and pulse, 15°/s–30°/s). Strengthening of 30 minutes, six sets of
eight repetitions, alternating flexion and extension movements
for each joint in concentric mode, 15°/s and 45°/s
45 minutes of passive elbow mobilization at 30°/s and 15°/s for
the wrist
Maximal concentric isokinetic strengthening (three sets of five 7 8
repetitions for flexors/knee extensors, plantar flexors and
ankle dorsiflexors (30°/s and 90°/s) of the affected limb) + CR
G2: CR (stretching, strengthening of the trunk and weakened
muscles of the arm and legs on the affected side, postural
control, balance training, weight shift, activities for daily living,
gait training)
IST for hip flexor/extensor, extensor/flexor of knee and 3 6
plantar flexors/dorsiflexor of the ankle at 60°/s (three sets of
five repetitions)
Functional strengthening + CR
Three sets at 5× flexion and concentric extension and 5× 5 4
flexion and eccentric extension of the knee, 60°/s
Three sets at 10× knee flexion/extension, 60°/s
Strengthening of the knee: five repetitions at speeds of 60°/s, 5 3
90°/s, 120°/s, and 150°/s
Strengthening of the ankle: five repetitions at speeds of 60°/s,
90°/s and 120°/s and 10 repetitions at 150°/s + CR
CR
Eccentric strengthening for hip flexors and extensors + CR 3 (60 minutes/day) 6
CR
Concentric strengthening for hip flexors and extensors at 3 (60–90 minutes/day) 6
90°/s and plantar flexion at 30°/s
Strengthening of shoulder and elbow flexors at 15°/s and wrist
extensors at 60°/s
(Continued)
9
 10

Table 2. (Continued)

Study Groups/isokinetic type Repetitions, velocity Frequency Length

(× per week) (week)
Sekhar et al.19 GE: IST Stationary bike heating for 10 minutes. Strengthening of hip – 6
GC: CR flexors and extensors with six to eight repetitions + static and
dynamic balance exercise
Stretching and strengthening lower limb
Shimodozono GE: IST + CR (Isokinetic IST for knee flexion and extension 60°/s, 100 Fisio + TO: 5 6
et al.20 Dynamometer Cybex 6000) repetitions + flexion strength training and knee extension 25 (two hours a day)
GC: CR repetitions AAS 1
CR
Kim et al.21 GE: IST of the trunk IST with velocity of 60°/s (2 × 8), 90°/s (2 × 10), and 120°/s – 4
GC: CR (2 × 12)
Neurological development and gait training
Seo et al.22 GE IST Eccentric (Dynamometer Strengthening of knee flexors and extensors at speeds of 3 6
Cybex 770) 60°/s, 120°/s, and 180°/s
GC: CR CR
Kim et al.23 GE: IST (Dynamometer Kin-Com) Heating Strengthening of five minutes with five repetitions Three sessions of 6
GC: Passive movement for flexors and extensors of hip and knee and dorsiflexors 45 minutes per week
(Dynamometer Kin-Com) and ankle plantar flexors at 60°/s, followed by five minutes of
stretching. Strengthening with three sets of 10 repetitions:
30 minutes, followed by five-minute cooling with stretching.
Even intervention for heating and cooling the G1.
Passive movement of three sets, 10 repetitions for each joint
quoted in G1
Engardt et al.24 GE: IST Eccentric (Dynamometer Heating of three sets of 10 sub-maximal repetitions at 60°/s 2 6
KIN-COM 500H) for knee extension. Strengthening of a maximum of 15
GC: IST Concentric (Dynamometer repeated sets of 10× at speeds of 60°/s, 120°/s, and 180°/s.
KIN-COM 500H) Each training session in addition to two long 20-second levels
of knee extensor muscles

GE: group experimental (isokinetic strengthening); GC: group control; IST: isokinetic strengthening; CR: conventional rehabilitation.
Clinical Rehabilitation 00(0)
Pontes et al. 11

Figure 2.  Isokinetic strengthening training group versus conventional rehabilitation group: muscle strength
(Review Manager (RevMan) version 5.3; The Cochrane Collaboration, 2013).
IST: isokinetic strengthening training; CR: conventional rehabilitation.

Figure 3.  Isokinetic strengthening training group versus conventional rehabilitation group: mobility
(Review Manager (RevMan) version 5.3; The Cochrane Collaboration, 2013).
IST: isokinetic strengthening training; CR: conventional rehabilitation.

Figure 4.  Isokinetic strengthening training group versus conventional rehabilitation group: gait speed
(Review Manager (RevMan) version 5.3; The Cochrane Collaboration, 2013).
IST: isokinetic strengthening training; CR: conventional rehabilitation.
12 Clinical Rehabilitation 00(0)
GRADE assessments
The quality of evidence according to the GRADE
system is presented in Electronic Supplementary
File 2. The quality of evidence for the outcomes
muscle strength and mobility were determined to
be moderate. The quality of evidence for the out-
come gait speed was determined to be low.
Discussion
The main results of our systematic review indi-
cate that isokinetic strengthening training in
addition to the conventional rehabilitation pro-
gram is effective in increasing the muscle
strength, mobility, and gait in post-stroke patients.
Isokinetic muscle strengthening represents a
potentially interesting technique of rehabilitation
for post-stroke patients.
This systematic review is important because it
analyzes isokinetic muscle strengthening as a
potential modality in the neurological rehabilita-
tion of post-stroke patients. For stroke patients, a
small change in strength may promote substantial
improvements in function. Isokinetic strengthening
training resulted in an increased muscle strength
(SMDs = 0.71) and gait speed (SMDs = 0.64),
which represents a moderate effect size.25
Strengthening training is the main focus of reha-
bilitation in stroke patients. Theoretically, this
group is most likely to benefit from strength train-
ing. Thus, isokinetic exercise is still an efficient
muscle-strengthening tool and may have a benefi-
cial strength effect.
The minimum clinically important difference
values for gait speed and 6-minute walk test, set at
0.10–0.20 m/s26 and 14.0–30.5  m,27 respectively.
Kim et al. reported that post-stroke patients treated
21
with isokinetic muscle strengthening achieved an
improvement of 0.14 m/s points in gait speed and
Şen et al.,16 achieved an improvement of 15 m in
6-minute walk test, indicating a clinically signifi-
cant improvement. However, despite of isokinetic
exercise in dynamometer equipment permit the
muscle to work in a dynamic mode, the equipment
difficult the training in a functional way because of
the static position and the limited ability to simulta-
neously exercise multiple joints required for func-
tional activities.28
The results of this review have important clini-
cal implications. Isokinetic muscle strengthening is
a method that enables the muscle to exert maxi-
mum strength within the exercise range of all joints
at a constant speed. An advantage of the isokinetic
strengthening exercises is that they can be used as
personalized muscle-strengthening techniques,
offering a graduated and secure program, with an
objective measure of the progress.28 In addition,
isokinetic training produces a faster rate of strength
gain and reduced muscle tenderness than isotonic
training.28,29 Despite the benefits, the isokinetic
dynamometers are expensive, require ample space,
and require technical abilities of the professional to
use the equipment.28 In addition, not all muscle
groups can be appropriately strengthened by device
limitations.
Recent systematic review and meta-analysis
have indeed confirmed the positive impact of mus-
cle strengthening in stroke patients.30 Isokinetic
strengthening training has demonstrated positive
effects on muscle strength and disability in the con-
text of other chronic diseases. The results of this
review are in accordance with the findings of pre-
vious systematic reviews on knee osteoarthritis
patients28 in the rehabilitation of obese subjects31
and patients with shoulder instability.32 However, it
is important to elucidate the relationship between
improvements in muscle strength and physical
functioning through future studies. In addition,
studies reported that the effective transfer between
strength training and function depends on the
degree of post-stroke weakness. Thus, even patients
with hemiparesis may also benefit from strength
training.33,34
Given the small pool of available studies, some
caution is warranted when interpreting our results.
A notable limitation of the included studies is their
small sample size. Overall, heterogeneity was
either substantial or considerable for the muscle
strength and gait outcomes. This could be explained
by the wide variety of the isokinetic strengthening
training. Moreover, the great variability between
outcome measures used in studies limited our ability
Pontes et al. 13
to perform other meta-analysis. Further investiga-
tion is required to explore how the positive effects
of isokinetic strengthening training can be sus-
tained over time and to determine the optimum
dosages, duration, and outcomes when used in
combination with peripheral muscle training.
Taking into account the available studies, this
systematic review with meta-analysis showed that
isokinetic strengthening training improves muscle
strength, mobility, and gait and should be consid-
ered an efficient method in post-stroke rehabilita-
tion. More well-designed RCTs are necessary to
determine the most appropriate methods (device,
intensity, frequency, and duration).
Clinical Messages
•• In post-stroke patients, isokinetic strength-
ening training improves muscle strength,
mobility, and gait.
•• Further well-designed randomized con-
trolled trials (RCTs) are needed before
isokinetic strengthening training is used
routinely.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
Supplemental Material
Supplemental material for this article is available online.
ORCID iD
Mansueto Gomes-Neto https://orcid.org/0000-0002
-0717-9694
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