Is water-based exercise as effective as land-based exercise in improving walking speed and leg muscle strength in stroke survivors?

INTERVENTION: Cross over trial design comparing an aquatic plyometric program with a land‐based plyometric program. There will be a one week wash‐out between the two different interventions. Aquatic plyometric program: 1. the aquatic program was developed in collaboration with a physiotherapist who has over 20 years of clinical experience in the delivery of aquatic exercise (AR). The program was developed using a combination of clinical experience and existing evidence‐based literature for plyometric training principles 2. The program will be delivered as a small group program by the undergraduate honours physiotherapy student and supervised by one of the two experienced physiotherapists involved in the study 3. participants will attend the aquatic exercise group twice a week for two weeks 4. the aquatic program will be delivered in a public hydrotherapy facility close to where the participants live. The pool is an enclosed purpose‐built hydrotherapy pool with both stair and hoist access. The water temperature is maintained at 32 degrees, and the depth is between 1m to 1.2m and appropriate for this project. 5. The program will take 30 mins and has total footfalls of 120 per class. Plyometric programs for healthy young athletes are usually around 240 footfalls per session so 120 per class was chosen as a conservative estimate for the chronic stroke survivors in the study 6. the program includes two sets of 10 reps of five plyometric exercises with 60 secs rest between sets and 3 minutes rest between each exercise ‐ warm up 5 mins walking across the pool in waist deep water ‐ 2 footed vertical jump in chest deep water ‐ high knee marching on the spot in chest deep water ‐ squat jump waist deep water ‐ skip (step hop) in chest deep water ‐ bounding from one foot to the other in chest deep water ‐ warm down 5 mins walking across the pool 7. attendance and individual exercise records will be maintained to determine adherence CONDITION: Stroke PRIMARY OUTCOME: Gait velocity ; a. Will be measured by walking along an 8m GAITrite mat ; b. Three repetitions “walking at a comfortable speed” ; c. Three repetitions “walking as quickly as safely possible without running” ; The average gait velocity for each speed will be recorded Plantarflexor power in a non‐weightbearing position ; a. Plantarflexion power will be measured using a hand‐held dynamometer ; b. Participants will lie on a plinth and the researcher will hold the hand‐held dynamometer on the ball of the foot and give the instruction “try to point your toe as fast and strongly as you can”. ; c. Three trials will be recorded, with the time to maximum force recorded Walking endurance ; a. Measured using the six minute walk test ; b. Participants will be asked to walk as many laps of the gym as possible in six minutes, with rests allowed whenever required. ; c. The total distance walked and number of rests will be recorded. ; SECONDARY OUTCOME: Acceptability of training programs ; a. This short series of questions asks participants to rate their perceptions of whether they think that the exercise programs will be beneficial or enjoyable. ; b. responses are scored on a 5 point Likert scale where 1 = strongly agree, 2 = agree, 3 = neither, 4 = disagree or 5 = strongly disagree. ; Balance confidence ; a. Balance confidence will be measured using the ABC6 ‐ the short form of the Activities Balance Confidence scale ; b. This short scale of 6 questions asks participants to rate their confidence that they won’t lose balance while doing different daily tasks eg walking on a rainy footpath ; Lower leg plantartflexor strength ; a. Plantarflexion strength will be measured using a hand‐held dynamometer ; b. Participants will be lying on a plinth and the researcher will hold the hand‐held dynamometer on the ball of the foot and give the instruction “try to point your toe as fast and strongly as you can”. ; c. Three trials will be recorded, with kgs of force recorded ; Patient's perception of pain / muscle soreness during the exercise program ; Participants will record their level of pain on a VAS scale from 0 (no pain) to 10 (worst possible pain) ; ; plantar flexor power during a vertical jump from standing ; a. Vertical jump will be measured using the Vertec system. The system consists of an upright pole with moveable plastic strips on the top. In standing, the participants is asked to reach as high as they can and the level reached is recorded. Then the subject is asked to perform a vertical jump, to reach as high as possible. The vertical jump is the difference in cms between the standing and jumping heights. ; b. The participant’s legs will also be videotaped during the jump using MyJump software on an iPhone or iPad. This software calculates the distance jumped from the difference between two frames in the video. This additional data collection method will be used to confirm the results from the vertic system ; INCLUSION CRITERIA: • First time stroke occurred > 3 months prior to enrolment in study • Community ambulant and able to walk no assistance or with a single stick for 10m • Deemed medically stable by a general practitioner • Ability to follow verbal commands • No significant musculoskeletal impairment that restricts their mobility • Not currnetly receiving active therapy for gait and mobility post stroke