Circuit class therapy for improving mobility after stroke

Abstract

Background: Circuit class therapy (CCT) offers a supervised group forum for people after stroke to practise tasks, enabling increased practice time without increasing staffing. This is an update of the original review published in 2010.

Objectives: To examine the effectiveness and safety of CCT on mobility in adults with stroke.

Search methods: We searched the Cochrane Stroke Group Trials Register (last searched January 2017), CENTRAL (the Cochrane Library, Issue 12, 2016), MEDLINE (1950 to January 2017), Embase (1980 to January 2017), CINAHL (1982 to January 2017), and 14 other electronic databases (to January 2017). We also searched proceedings from relevant conferences, reference lists, and unpublished theses; contacted authors of published trials and other experts in the field; and searched relevant clinical trials and research registers.

Selection criteria: Randomised controlled trials (RCTs) including people over 18 years old, diagnosed with stroke of any severity, at any stage, or in any setting, receiving CCT.

Data collection and analysis: Review authors independently selected trials for inclusion, assessed risk of bias in all included studies, and extracted data.

Main results: We included 17 RCTs involving 1297 participants. Participants were stroke survivors living in the community or receiving inpatient rehabilitation. Most could walk 10 metres without assistance. Ten studies (835 participants) measured walking capacity (measuring how far the participant could walk in six minutes) demonstrating that CCT was superior to the comparison intervention (Six-Minute Walk Test: mean difference (MD), fixed-effect, 60.86 m, 95% confidence interval (CI) 44.55 to 77.17, GRADE: moderate). Eight studies (744 participants) measured gait speed, again finding in favour of CCT compared with other interventions (MD 0.15 m/s, 95% CI 0.10 to 0.19, GRADE: moderate). Both of these effects are considered clinically meaningful. We were able to pool other measures to demonstrate the superior effects of CCT for aspects of walking and balance (Timed Up and Go: five studies, 488 participants, MD -3.62 seconds, 95% CI -6.09 to -1.16; Activities of Balance Confidence scale: two studies, 103 participants, MD 7.76, 95% CI 0.66 to 14.87). Two other pooled balance measures failed to demonstrate superior effects (Berg Blance Scale and Step Test). Independent mobility, as measured by the Stroke Impact Scale, Functional Ambulation Classification and the Rivermead Mobility Index, also improved more in CCT interventions compared with others. Length of stay showed a non-significant effect in favour of CCT (two trials, 217 participants, MD -16.35, 95% CI -37.69 to 4.99). Eight trials (815 participants) measured adverse events (falls during therapy): there was a non-significant effect of greater risk of falls in the CCT groups (RD 0.03, 95% CI -0.02 to 0.08, GRADE: very low). Time after stroke did not make a difference to the positive outcomes, nor did the quality or size of the trials. Heterogeneity was generally low; risk of bias was variable across the studies with poor reporting of study conduct in several of the trials.

Authors' conclusions: There is moderate evidence that CCT is effective in improving mobility for people after stroke - they may be able to walk further, faster, with more independence and confidence in their balance. The effects may be greater later after the stroke, and are of clinical significance. Further high-quality research is required, investigating quality of life, participation and cost-benefits, that compares CCT with standard care and that also investigates the influence of factors such as stroke severity and age. The potential risk of increased falls during CCT needs to be monitored.

Conflict of interest statement

Coralie English: has published a trial investigating the use of CCT with people with stroke (English 2015). Susan Hillier: has published a trial investigating the use of CCT with people with stroke (English 2015). Elizabeth Lynch: none known

Figures

1

PRISMA flow diagram

2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

3

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

1.1. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 1 6mWT early and late.

1.2. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 2 Gait speed early and late.

1.3. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 3 Cadence.

1.4. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 4 Timed Up and Go.

1.5. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 5 Rivermead Mobility Index.

1.6. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 6 Functional Ambulation Classification.

1.7. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 7 Berg Balance Scale.

1.8. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 8 Step Test.

1.9. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 9 Activities‐specific Balance Confidence Scale.

1.10. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 10 Stroke Impact Scale (physical).

1.11. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 11 VO2 peak.

1.12. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 12 Steps per day.

1.13. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 13 Length of stay.

1.14. Analysis

Comparison 1 Circuit class therapy versus other, Outcome 14 Sensitivity: 6mWT.

2.1. Analysis

Comparison 2 CCT + education versus no therapy, Outcome 1 Timed Up and Go.

2.2. Analysis

Comparison 2 CCT + education versus no therapy, Outcome 2 Carer Strain Index.

3.1. Analysis

Comparison 3 CCT +/‐ education versus any other intervention, Outcome 1 Adverse events (falls).